Question

PREOPERATIVE DIAGNOSIS : Painful hardware, left foot.

POSTOPERATIVE DIAGNOSIS : Painful hardware, left foot.

PROCEDURE PERFORMED : Removal of hardware, left foot.

ANESTHESIA : Sedation and local.

DRAIN : None.

ESTIMATED BLOOD LOSS : Minimal.

INDICATIONS FOR PROCEDURE :

The patient had his status post metatarsal fracture, treated with internal fixation. The patient has suffered pain due to hardware for the past six months. Patient's pain has been unresponsive to conservative treatment. We discussed the above-mentioned surgery, along with the potential risks and complications, and the patient understood and wished to proceed.

DESCRIPTION OF PROCEDURE :

With the patient supine on the operating table after the successful induction of anaesthesia, the left foot was prepped and draped in the usual sterile fashion. In the area of the screw heads, 0.5% Marcaine was injected, both on the lateral side of the foot and the dorsal midfoot, administering about 5 ml in each area. Small 0.5 cm incisions through the skin were made and blunt dissection was carried down to the screw heads. The screws were removed with the screwdrivers. The incisions were irrigated and closed with simple 4-0 nylon sutures. A sterile compression dressing was applied. The patient was taken to the recovery room in satisfactory condition.

MATERIAL SENT TO LABORATORY : None.

COMPLICATIONS : None.

CONDITION ON DISCHARGE : Satisfactory.

DISCHARGE DIAGNOSIS : Painful hardware, left foot.

DISCHARGE PLAN :

Discharge instructions were discussed with the patient. A copy of the instructions was given to the patient and a copy retained for the medical record. The following items were discussed: diet, activity, wound care medications if applicable when to call the physician and follow-up care.

What are the CPT® and ICD-10-CM codes reported?

Answer 1

The CPT code reported for the removal of hardware from the left foot is 20680, and the ICD-10-CM code for painful hardware in the left foot is M96.662. These codes are derived from the CPT manual and ICD-10-CM classification based on the surgical report.

Step-by-step explanation:

The CPT code for the removal of hardware from the left foot is 20680, as this is the code used for the removal of deep hardware. The ICD-10-CM code that best describes the diagnosis for painful hardware is M96.662, which indicates the presence of painful postoperative orthopedic hardware in the left lower limb.

In order to determine these codes, one would refer to the Current Procedural Terminology (CPT) and the International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM). The healthcare provider's documentation, in this case the surgical report, provides the necessary details for accurate coding. Procedure codes are chosen based on the specific actions performed by the healthcare provider, while diagnosis codes capture the underlying conditions or reasons for the procedure.