Find comprehensive information on Removal of Deep Intramedullary Nail from Hip including CPT codes, ICD-10 codes, clinical documentation requirements, postoperative care, and potential complications. This guide covers healthcare coding, medical billing, and physician documentation for intramedullary nail removal surgery, hip revision surgery, and related orthopedic procedures. Learn about appropriate medical terminology, documentation best practices, and coding guidelines to ensure accurate reimbursement and optimal patient care for deep intramedullary nail removal from the hip.
Also known as
Removal of intramedullary implants
Removal of internal fixation devices from femur/hip.
Removal of plates from lower limb
Removal of orthopedic plates from lower extremity bones.
Removal of other int fix devices
Removal of various internal fixation devices from bones.
Follow this step-by-step guide to choose the correct ICD-10 code.
Was the nail removal routine?
Yes
Code 0QBN0ZZ Removal of intramedullary implant from right hip, routine
No
Was there complication?
When to use each related code
| Description |
|---|
| Removal of hip nail |
| Broken hip, initial encounter |
| Delayed healing of hip fracture |
Coding may lack laterality (left/right) or specific hip region, leading to claim denials or inaccurate data.
Missing documentation of nail removal method (e.g., open, percutaneous) can affect code selection and reimbursement.
Failure to document original nail insertion date and reason may hinder accurate coding and medical necessity reviews.
Procedure: Removal of deep intramedullary nail from hip. Indication: The patient presented for planned removal of a previously placed intramedullary nail in the right proximal femur. The original indication for nail placement was a closed, displaced femoral shaft fracture. The fracture has now clinically and radiographically healed. Preoperative radiographs confirmed solid bony union. The patient denies any pain, discomfort, or functional limitations related to the healed fracture site. Risks and benefits of the procedure, including infection, bleeding, nerve damage, and refracture, were discussed with the patient, and informed consent was obtained. Anesthesia: General anesthesia. Surgical Technique: The patient was positioned supine on the operating table. A standard surgical prep and drape was performed. A longitudinal incision was made over the previous surgical site. The proximal end of the nail was identified and the interlocking screws were removed. The intramedullary nail was then carefully extracted without complication. Hemostasis was achieved. The incision was closed in layers with absorbable sutures. A sterile dressing was applied. Postoperative Course: The patient tolerated the procedure well. Neurovascular examination of the extremity remained intact postoperatively. Postoperative radiographs confirmed complete removal of the intramedullary nail and hardware. The patient was discharged home on the same day with instructions for wound care, pain management, and activity restrictions. Follow-up in the clinic is scheduled in two weeks. Diagnosis: Status post intramedullary nailing of the femur, healed femoral shaft fracture, hardware removal. Keywords: Intramedullary nail removal, hip surgery, femoral nail removal, hardware removal, fracture healing, postoperative care, deep intramedullary nail, orthopedic surgery, general anesthesia, proximal femur fracture, complication management, informed consent, medical billing, coding, ICD-10, CPT, electronic health records, EHR documentation.