Coding gurus, I’m at a loss on this one. We had a patient that had ORIF of a proximal humerus fracture and then, a month later had a second procedure.
Indications: Prominent hardware and suture abscess.
Operation Performed: Left shoulder superficial I and D with exchange of proximal locking screws.

Should I code unlisted for the hardware exchange, or could I code repeat ORIF with reduced services?

Description of procedure:
“…….no fluid collection or purulence was found in the subcutaneous or deep tissues. The areas around the suture abscess was cultured anyway. This area was copiously irrigated and the soft tissues were dissected to ensure there were no pickets of infection or purulence. After utilizing the deltopectoral interval, the proximal portion of the previously placed plate was exposed. The fracture site was palpated and found to be firm and stable. The C-arm was sterilely draped and brought onto the field and screws, which appeared to be threatening the penetration of the subchondral bone were identified and removed. These were then exchanged for shorter screws with the aid of fluoroscopy to ensure appropriate length”

Thanks,
Tobi C.