20680 - Removal of implant;
deep (eg, buried wire, pin, screw, metal band, nail, rod or plate)
An internal fixation device or implant is removed. Internal fixation devices or implants are used to fix and support bones that have been fractured or weakened by a disease process. Some implants are removed while others are left in the bone. The skin is incised at the site of the implant and the implant is exposed. The bone and implant are inspected and the implant is carefully removed. Use
20670 when a superficial implant, such as a buried wire, pin, or rod is removed. Use
20680 when a deep implant, such as a buried wire, pin, screw, metal band, nail, rod, or plate is removed.
This has plurality in the definition. Here is helpful information from CPT Assistant:
When the fracture is stable or healed, all forces are borne by the bone. At this point, the external fixation is no longer needed and can be safely removed. Subsequent casting, bracing, or surgery may also follow the removal of external fixation. CPT codes
20690-
20697 relate to the application, adjustment and removal, of an external fixation system. CPT code
20694, Removal, under anesthesia, of external fixation system, would be appropriately reported only when anesthesia is required to perform removal of the external fixator system.
Removal of the external fixator performed without anesthesia is not a separately reportable procedure because
local infiltration of medication(s), anesthetic or contrast agent before, during, or at the conclusion of the procedure is an inclusive service of codes
20670,
20680, and
20690.
Code
20680, Removal of implant; deep (eg, buried wire, pin, screw, metal band, rod or plate), describes a unit of service that is reported only once provided the original injury is located on one site, regardless of the number of screws, plates, rods or incisions. An example would be the removal of a single implant system, which may call for "stab" or multiple incisions (eg, intramedullary (IM) nail and several locking bolts).
Multiple use of code
20680 would be appropriate only when the hardware removal was performed for another fracture in a different anatomical site unrelated to the first fracture (eg, ankle and humerus). In these circumstances, modifier
59, Distinct procedural service, would be appended to subsequent uses of the code. For example, two different and noncontiguous implants are removed from two different bones or two different (noncontiguous) sites on the same bone using multiple incisions. Depending on whether the implants were superficial or deep, code
20680 may be reported twice or codes
20680 and
20670,
Removal of implant; superficial (eg, buried wire, pin, or rod (separate procedure), may each be reported.
If there was an extraordinary amount of work, or unusual effort involved in the removal (eg, bone buried screws or an exceptional scar), then modifier
22, Increased procedural services, may be appended to the code for the procedure and submitted with the usual accompanying documentation.
Examples of Use of Codes
20670 and
20680
To assist coders in discerning whether to use code
20670 or
20680, the following examples discuss a single implant, single and multiple fracture treatment, and specific products.
Removal of Deep or Superficial Bimalleolar Plate and Screws
Code
20680 would be used to describe the removal of a plate (eg, periarticular plate, locking plate, or one-third tubular plate) and screws from the fibula in a healed bimalleolar ankle fracture. If deep buried medial malleolar screws are removed from the tibia's medial malleolus at the same session, use code
20680.
If removing superficial screws from the fibular fracture, code 20670 should be reported. If superficial screws are removed from the tibia's medial malleolus at the same session, the procedure is reported using code
20670 with modifier 59 appended.
Removal of Plate and IM Nail and Interlocking Screws—Proximal Tibial Plateau and Tibial Shaft Fractures (Noncontiguous Fractures)
During the same surgical session, if a plate and its associated screws are removed from a healed proximal tibial plateau fracture, and an IM nail with its interlocking screws are removed through a separate skin or fascial incision from a healed tibial shaft fracture where both implant systems were used in the same tibial bone for noncontiguous fractures, report code
20680 for one of the implant systems (eg, plate and screws) and code
20680 with modifier 59 appended for the other implant system removal (eg, IM nail and screws).
Recognize that the plate and all of its associated screws can be removed through one long extensile incision, or the plate and some screws may be removed through a smaller, less-invasive incision, with the remaining screws being removed through smaller stab incisions. In either instance, code
20680 should be reported only once for the plate and screw system removal. Also recognize that IM nail systems (ie, nail and interlocking screws) cannot be removed through one extensile incision, but are routinely removed through a larger incision for IM nail removal and one or more smaller incisions for removal of one or more interlocking screws. Therefore, code
20680 should be reported only once for the removal of the IM nail and any or all of the interlocking screws when performed on the same day by the same physician.
Removal of Separate Plate/Screw Systems—Both Bone Forearm Fracture
Code
20680 is reported once for each bone when removing internal fixation of healing fractures of "both bones" (radius and ulna) of the forearm when each bone is treated with separate plates and screws. If the plate and screw system is removed from the ulna at the same session as the radius, code
20680 with modifier 59 appended is reported. These plates may be described by size (eg, small fragment system or small fragment plate) or by a trademark or type (eg, locking plate, periarticular plate, or polyaxial locking plate). Alternatively, the hardware may be described by the name of the manufacturer. Each plate and screw system removal procedure would be reported separately using code
20680 with modifier 59 appended to denote distinct procedural services (eg, different site or separate incision) performed on the same day by the same physician. Removal of any and all screws used for each fixation system (ie, one plate and its associated screws) is part of the service of the plate removal.
References
American Medical Association,
CPT Assistant, Coding for External Fixation, October 1999, Volume 9, Issue 10, page 5.
Radiological Society of North America,
Orthopedic Fixation Devices, Radiographics, Vol 11, 823-847, Copyright©1991 by Reviews, RM Slone, MM Heare, RA Vander Griend and WJ Montgomery, Department of Radiology, University of Florida, College of Medicine, J. Hillis Miller Health Center, Gainesville, FL.
