CCO Admin asked:
Hi; Can someone tell me which would be the appropriate code for revision of internal fixation. The provider states the correct code is hardware removal 20680; but after reading the note; no hardware was removed. The 2 screws were just tighten back to the plate. I could understand if we replaced the screws... I am looking for a second opinion on code selection.
"Attention was directed to prominent area where screw was backing out. Utilizing the inoperative fluoroscopy; two screws that were backing out; were identified and marked on the skin.....Next; stab incisions was created over the capsule and screw head was noted on both sites of stab incisions. Next; using the appropriate screwdriver from the Medline; screw was identified as screw back in to the plate until it was locked on the plate...Inoperative fluropscopy was used to identify that screw was adequately locked into plate...."
I do not feel that 20680 is correct due to nothing was removed but rather screws were just tightened. Any code suggestions or insight would be greatly appreciated.
Answer:
I would use the prior cpt procedure code with modifier 78. Return to the OR due to complications of internal fixation device.
Hi; Can someone tell me which would be the appropriate code for revision of internal fixation. The provider states the correct code is hardware removal 20680; but after reading the note; no hardware was removed. The 2 screws were just tighten back to the plate. I could understand if we replaced the screws... I am looking for a second opinion on code selection.
"Attention was directed to prominent area where screw was backing out. Utilizing the inoperative fluoroscopy; two screws that were backing out; were identified and marked on the skin.....Next; stab incisions was created over the capsule and screw head was noted on both sites of stab incisions. Next; using the appropriate screwdriver from the Medline; screw was identified as screw back in to the plate until it was locked on the plate...Inoperative fluropscopy was used to identify that screw was adequately locked into plate...."
I do not feel that 20680 is correct due to nothing was removed but rather screws were just tightened. Any code suggestions or insight would be greatly appreciated.
Answer:
I would use the prior cpt procedure code with modifier 78. Return to the OR due to complications of internal fixation device.
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