Deep Hardware and implant removal coding

There are two circumstances where deep hardware or implant removal is required.

1. As an aftercare for healed fracture.

2. If the implant or hardware causes pain or irritation.

CPT has two codes for hardware removal:

20670

Removal of superficial implant

20680

Removal of deep implant

ICD has procedure codes for hardware removal are in 78.6x subcategory. For  removal of implanted device from facial bones 76.97.

EXAMPLE:

PREOPERATIVE DIAGNOSIS:

Left foot retained hardware, two 7.3 mm cannulated screws.

POSTOPERATIVE DIAGNOSIS:

Same as above.

Notes

OPERATION PERFORMED:

Left foot removal of painftil hardware .

DX  CODE   DESCRIPTION  

1     996.78  Complication NEC Int Orth Device/Implant/Graft NEC

2     338.18  Other Acute Postoperative Pain

3     E878.1  Abnormal Reaction in Surg Implant Internal Device

4     E849.9  Accident Occurring in Place NOS

PX   CODE   DESCRIPTION  

1     78.69 Removal implanted device bone from foot.   

CPT CODE  DESCRIPTION        

1    20680 Removal of deep implant