Chart reads this woman went in for elective removal of a plate and pins in her ankle due to pain 10mths post bimalleous ankle fracture.
As it would turn out there is a lag screw by the distal fibula. This is a medical misadventure, is it not? Making it an Ecode candidate as well?
I have '996.40' & 'E878.1'
The reason for elective removal of plate / pins in ankle is pain. Therefore the primary Dx code should be --> 996.78. Look for the descriptor below the 996.7 series -- "Pain - due to (presence of) any device, implant, and graft classifiable to 996.0-996.5". As for the secondary Dx, E878.1, or E871.0 could be a code of choice.
