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Coding tip: Deep vs. superficial pin removal

Ambulatory Surgery Reimbursement Update, December 4, 2007

You would code procedure codes for the removal of internal fixation devices, screws, wires, and pins and modification/removal of these devices using CPT code 20670 for the removal of a superficial implant or CPT code 20680 for removal of a deep implant (buried wire, pin, screw, or rod), which requires a surgical procedure.

If the physician performs the removal as a separate procedure from another procedure during the same case, you may bill this service. On the other hand, when the physician performs the service in conjunction with another procedure involving the same area, you may not separately bill it. It is advisable to check the Correct Coding Initiative (CCI) material.

Use code 20670 for superficial pin removal when the physician makes a small incision overlying the site of the implant, and the physician removes the implant by pulling or unscrewing it. The incision is closed with sutures/steri-strips (no layered closure is involved).

This code is designated as a separate procedure in the CPT Manual. Use code 20680 for deep pin removal procedures, (which are usually done in an ASC). The physician makes an incision overlying the site of the implant using deep dissection to visualize the implant (usually below the muscle level and within bone). Using instruments to remove the implant from the bone. The physician repairs the incision in multiple layers using sutures, staples, etc.

This tip is brought to you by Ellis Medical Consulting, Inc.