"Question: How should I code the removal of hardware in the ankle? I am removing a screw used for an ankle syndesmosis fixation (distal tibio-fibular joint). This was planned and originally placed at the time of the open reduction, internal fixation (ORIF) (27828, open treatment of fracture of weight bearing articular surface/portion of distal tibia [e.g., pilon or tibial plafond], with internal fixation or external fixation; of both tibia and fibula). Code 20680 is used for deep/buried implant removal, but according to ICD-9, the only possibilities for cross-reference are codes listed as complications of mechanical and implantable devices. The screw is not being removed due to complication, but rather as a planned procedure so the patients weight-bearing status can be advanced.
Answer: Use V54.0 (aftercare involving removal of fracture plate or other internal fixation device) as the diagnostic code for the screw removal. Modifier -58 (staged or related procedure by the same physician during the same postoperative period) is also appropriate because the surgery to remove the screw is taking place during the global period of the original surgery.
Because the screw removal was not a complication of the original surgery, but an anticipated occurrence, modifier -78 (return to the operating room for a related procedure during the postoperative period) is not appropriate; the return to surgery was already planned.
Answers to Reader Questions and You Be the Coder were provided by Heidi Stout, CPC, CCS-P, coding and reimbursement manager at University Orthopedic Associates in New Brunswick, N.J.; and Susan Callaway, CPC, CCS-P, an independent coding consultant and educator based in North Augusta, S.C."