AHA Coding Clinic® for ICD-10-CM and ICD-10-PCS - 2023 Issue 1; Ask the Editor

Removal of S2-Alar-Iliac Screws

A patient with a history of prior L1-L5 fusion with XLIF cages and an extension of fusion down to S2 with alar-iliac (S2AI) screws presents for surgical intervention due to pain from prominent hardware and the S2AI screws. During surgery, a dissection was made from T10 to the sacrum including the S2AI screws, taking down all the posterior elements and all the old hardware, including set screws and rods, secondary to looseness. The S2AI screws were removed and an attempt was made to place a new S2AI screw on the left as well as the right, however due to prior complaints of significant pain from the old S2AI screws, a decision was made not to place S2AI screws at this juncture. What is the correct code assignment to capture the removal of the S2AI screws? ...

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