tci Part B Insider - 2014 Issue 3

Reader Question: Not All Hardware Removals Are Payable

Question: My physician’s note states, “Previous incisions incised.....bluntly dissected down onto screw heads. Guidewires were placed. One screw was backed out, the other was advanced 7 mm. The lateral incision was incised approximately 2.5 cm on the fibula. Dissection carried down onto suture material, which was removed without difficulty. Wounds were irrigated and closed. Dx: prominent medial hardware.” Do I code anything other than 20680 for: 1. Removal of medial malleolar screw. 2. Advancement of secondary medial malleolar screw beneath the bone. 3. Removal of lateral sutures? Answer: You should report the screw extraction...

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