Darshna Posted Mon 18th of December, 2017 11:38:35 AM
Hi my provider did below procedure.
1. Removal of deep orthopedic implant x3, left lower extremity
2. Complex closure of wound approximately 5 cm
3. Irrigation debridement of skin, soft tissue and bone
4. Use of intraoperative fluoroscopy, less than 1 hour
I have submitted claim with CPt 13121, 11044 & 20680.
CPT 13121 & 11044 was denied as operative reports not support this code.
SuperCoder Answered Tue 19th of December, 2017 06:18:48 AM
CPT code 20680 is for Removal of implant; deep (eg, buried wire, pin, screw, metal band, nail, rod or plate), in this procedure the patient is appropriately prepped and anesthetized, the provider re-opens the original incision and extends the incision by dissecting through fascia and muscle layers to access the deep bone implant, such as a rod, pins, wire, screw, metal band, nail, rod, or plate. When provider identifies the deeply inserted implant, she unscrews the implant, dissecting it from surrounding tissue as necessary. She extracts the deep implant by pulling it out with sharp forceps. She closes the wound with layered sutures. Hence, closure of wound and debridement (11044, 13121) will not be paid separately.
Informational: A provider performs two hardware removals on the same body part on the same day, but he performed them through separate incisions. According to the American Academy of Orthopaedic Surgeons, you should report CPT 20680 regardless of how many screws the provider removed.