AHA Coding Clinic® for ICD-10-CM and ICD-10-PCS - 2023 Issue 2; Ask the Editor

Intraoperative Tibial Fracture During Staple Removal

A patient with left knee osteoarthritis, varus contracture and previous anterior cruciate ligament repair presented for a total knee arthroplasty. During surgery, old staples in the tibia were encountered; these were felt best to be removed. With the use of a slap hammer set, one of the staples was grasped but its removal created a cortical fracture encompassing 4cm of the metaphyseal bone. The surgeon documented that the fracture of the medial tibial plateau was a complication of the procedure. What code(s) is assigned for the intraoperative fracture of the medial tibial plateau that occurred during staple removal? ...

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