“I have an unusual situation that I am trying to figure out how to code. I had a patient return to the office in the global period after I preformed a 1st metatarsophalangeal joint (MTPJ) arthrodesis. Although, the alignment of the fusion looks good, one of the non-locking screws advanced out of the bone and plate and started to tent the skin at the incision site at three weeks post operative. She is neuropathic and denied any trauma to the area. I removed the screw in the office with local anesthesia. Can I bill for unplanned screw removal in the office?”
So, we are in the postoperative global period following a 1st MTPJ arthrodesis. There is an issue with the hardware. One of the non-locking screws is essentially backing out of the bone plate and is starting to press against the incision site. To answer the question simply, YES, the unplanned screw removal can be billed in the office. Let’s discuss the scenario.
As far as the appropriate CPT code to bill for the removal of the screw, it is important to access the 2024 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 post, 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
Based upon the fact that the screw in question has “advanced out of the bone,” and “started to tent the skin at the incision site,” 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. Remember, this “complication” took place 3 weeks into the postoperative global period. Therefore, an appropriate modifier needs to be appended to CPT 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 correct coding scenario would be the following:
CPT 28190 – RT/LT, 78
This is my opinion.
Michael G. Warshaw, DPM, CPC
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