Hardware removed as part of revision

Read an original fictional chart, identify the supported facts, and explain your coding workflow.

Chart gym · Original fictional record

Service date: 2026-09-09 · Medicare musculoskeletal professional service

Use your code books and write your reasoning before opening the walkthrough. This exercise contains no real patient information.

Operative indication

Synthetic record, September 9, 2026. An adult has a physician-diagnosed aseptic nonunion of the left tibial shaft after prior plate fixation. Imaging and examination support revision. The retained plate and screws obstruct access to the nonunion and cannot remain for the planned revision fixation.

Signed operative report

The surgeon exposes the left tibial nonunion, removes the old plate and screws, prepares the nonunion site and corrects alignment. A new plate-and-screw construct stabilizes the tibia. The surgeon documents that removal of the prior construct was necessary to complete this revision. No hardware is removed from another site.

Completion record

The surgeon confirms alignment and fixation, achieves hemostasis and closes the wound. The implant log lists the old plate and each removed screw, followed by the new construct. There is no separate elective hardware-removal procedure or other anatomical target.

Procedure worksheet

A draft adds separate removal lines for the old plate and individual screws to the revision procedure. Evaluate inclusion before counting removal units. Use the actual tibial site, nonunion repair and fixation technique for the full authorized-entry lookup; this worksheet does not supply a final revision code.

Your coding worksheet

Identify why the old fixation was removed.
Relate the removal to the completed left-tibial revision.
Evaluate the proposed separate plate and screw removal lines.
Identify the site and completed technique needed for the revision-entry lookup.

In your notebook, record the supported facts, your index route, the instructions you checked, and any missing detail that limits your answer.

Compare with the worked explanation

The old fixation obstructs the work required for revision of the left tibial nonunion. Its removal is integral to the same-site revision.
Under NCCI G.10, removal of that fixation is not a separately reportable procedure in this operation.
Even a separately reportable implant removal would use anatomical-site units under H.3, not one unit per screw or plate. Here inclusion is resolved first, so no separate removal unit is added.
Complete the authorized nonunion-repair lookup from the documented tibial site and actual procedure. The word nonunion alone does not choose the final entry.

Reference sections: G.10; H.3

Practice the linked chart questions