Failed Hardware Removal

Question:

Our surgeon attempted to remove deep hardware in the operating room but was unable after multiple attempts. No other surgical procedures were performed. Are we able to bill anything for the attempted surgery?

Answer:

Yes, you may. Your scenario indicates “deep hardware” indicating CPT code 20680 (Removal of implant; deep (eg, buried wire, pin, screw, metal band, nail, rod or plate) is the correct code. Append modifier 52, reduced service modifier to CPT code 20680 to indicate the service was attempted but not achieved.

*This response is based on the best information available as of 07/22/21.