A patient had a first metatarsophalangeal joint fusion/arthrodesis performed. Approximately 1 month following the procedure, one of the screws that was used to perform the procedure backed out of the bone and the plate that was applied to the 1st MPJ and started to apply pressure beneath the underlying skin at the site of the surgical incision. The screw needed to be removed. What would be the most appropriate CPT code to bill?
As far as the appropriate CPT code to bill for the removal of the screw, it is important to access the 2023 CPT Manual. Under Surgery Guidelines, you need to access the “Foreign Body/Implant Definition.”
“An object intentionally placed by a physician of other qualified health care professional for any purpose (eg. diagnostic or therapeutic) is considered an implant. An object that is unintentionally placed (eg. trauma or ingestion) is considered a foreign body. If an implant (or part thereof) has moved from its original position or is structurally broken and no longer serves its intended purpose or presents a hazard to the patient, it qualifies as a foreign body for coding purposes, unless CPT coding instructions direct otherwise or a specific CPT code exists to describe the removal of that broken/moved implant.”
Based upon the issue that is identified within in the above scenario, the screw that needs to be removed would be considered a foreign body. Therefore, the following CPT code set would need to accessed in order to determine the most appropriate CPT code to bill.
If Foreign Body is Removed,
CPT 28190 Removal of foreign body, foot; subcutaneous
CPT 28192 Removal of foreign body, foot; deep
CPT 28193 Removal of foreign body, foot; complicated
Do to the fact that the screw in question has “backed out of the bone,” and “started to apply pressure beneath the underlying skin at the site of the surgical incision,” this would not be classified as “removal of foreign body deep,” but would be classified as “removal of foreign body, subcutaneous. Therefore, the most appropriate CPT code to bill would be CPT 28190 which is defined as: Removal of foreign body, foot; subcutaneous. Since this “complication” took place approximately 1 month into the postoperative global period, an appropriate modifier needs to be appended to CPT code 28190. This would be the 78 modifier which is defined as the following: UNPLANNED RETURN TO THE OPERATING/PROCEDURE ROOM BY THE SAME PHYSICIAN FOLLOWING INITIAL PROCEDURE FOR A RELATED PROCEDURE DURING THE POSTOPERATIVE PERIOD – COMPLICATION MODIFIER – It may be necessary to indicate that another procedure was performed during the postoperative period of the initial procedure (unplanned procedure following initial procedure). When this procedure is related to the first and requires the use of an operating or procedure room, it may be reported by adding modifier 78 to the related procedure.
The appropriate coding scenario would be the following:
CPT 28190 – RT/LT, 78
This is my opinion.
Michael G. Warshaw
THE 2023 PODIATRY CODING MANUAL IS NOW AVAILABLE in either Book or Flashdrive formats. It has been completely updated including the 2023 E/M coding changes. Many offices across the country consider this to be their “Bible” when it comes to coding, billing and documentation. The price is still only $125 including shipping! To purchase, access the website drmikethecoder.com.
No credit card? No problem! Just send a check for $125 to the following address:
Dr. Michael G. Warshaw
2027 Bayside Avenue
Mount Dora, Florida 32757