ICD 10 Coding Alert

Specialty Spotlight:

Bone Up on Your Ankle Fracture Coding

Published on Mon Jan 03, 2022

Hint: A bimalleolar fracture involves two bones.

Fractures are tricky to code because “fracture” can encompass so many different situations. Because ankles are comprised of multiple bones, coding ankle fractures can be especially tricky.

Make sure you’re double-checking documentation for location, type of fracture, encounter details, and how the fracture is healing to ensure you’re getting the revenue you’ve earned and deserve.

Locate Correct ICD-10-CM Code for Bimalleolar Fracture

Question 1: The patient has a displaced bimalleolar fracture of the right lower leg. This was a subsequent encounter for an open fracture type I with delayed healing. What is a bimalleolar fracture, and what ICD-10-CM code should I report on my claim?

Answer 1: In this case, you should report code S82.841H (Displaced bimalleolar fracture of right lower leg, subsequent encounter for open fracture type I or II with delayed healing) on your claim.

Definition: A bimalleolar ankle fracture involves two bones: the medial, distal, end of the tibia — or medial malleolus; and the distal, outside, end of the fibula — or lateral malleolus. Additionally, a bimalleolar fracture can also be a break of the medial and posterior malleoli or the lateral and posterior malleoli.

Select Correct Option for Bimalleolar Fracture Treatment

Question 2: My podiatrist performed closed treatment of a lateral and medial malleoli ankle fracture without manipulation. Which CPT® code should I report for this procedure?

Answer 2: You should report 27808 (Closed treatment of bimalleolar ankle fracture (eg, lateral and medial malleoli, or lateral and posterior malleoli or medial and posterior malleoli); without manipulation) in this case. A lateral and medial malleoli ankle fracture is an example of a bimalleolar fracture.

Don’t Miss Codes for Lateral Malleolus Ankle Fracture

Question 3: My podiatrist documented a displaced fracture of the lateral malleolus of the right fibula. This was an initial encounter for an open fracture type IIA. What ICD-10-CM code should I report for this injury?

Answer 3: You should report S82.61XC (Displaced fracture of lateral malleolus of right fibula, initial encounter for open fracture type IIIA, IIIB, or IIIC) on your claim.

Definition: When a patient has a lateral malleolus fracture, he has a fracture at the end of his fibula.

Note When Manipulation Is Used

Question 4: My podiatrist performed closed treatment of a lateral malleolus fracture without manipulation. He also applied a cast. Which CPT® code should I report on my claim?

Answer 4: You should report 27786 (Closed treatment of distal fibular fracture (lateral malleolus); without manipulation) in this case.

Don’t miss: If your podiatrist had performed closed treatment of a lateral malleolus fracture with manipulation, then you would report code 27788 (... with manipulation).

Turn to This ICD-10-CM Code Set for Medial Malleolus Fracture

Question 5: According to the medical documentation, the patient has a nondisplaced fracture of the medial malleolus of the left tibia. This was an initial encounter for a closed fracture. What is a medial malleolus fracture, and what ICD-10-CM code should I report on my claim?

Answer 5: You should report S82.55XA (Nondisplaced fracture of medial malleolus of left tibia, initial encounter for closed fracture) on your claim.

Definition: A medial malleolus fracture is a fracture of the inner side of the ankle at the end of the tibia.

Pocket These Surgical Medial Malleolus Options

Question 6: My podiatrist had to surgically visualize a medial malleolus fracture. This surgery required exposure to the environment. Which CPT® code should I report for this procedure?

Answer 6: For open treatment of a medial malleolus fracture, you should report 27766 (Open treatment of medial malleolus fracture, includes internal fixation, when performed), according to Arnold Beresh, DPM, CPC, CSFAC, in West Bloomfield, Michigan.

Use Prefix Hint for Trimalleolar Fracture

Question 7: Per the medical documentation, the patient has a displaced trimalleolar fracture of the left lower leg. This was a subsequent encounter for an open fracture type I with delayed healing. What is a trimalleolar fracture, and which ICD-10-CM code should I report?

Answer 7: You should report S82.852H (Displaced trimalleolar fracture of left lower leg, subsequent encounter for open fracture type I or II with delayed healing).

Definition: A trimalleolar fracture involves the medial malleolus and lateral malleolus and includes a posterior malleolus fracture, as well. It involves three bones.

Report Closed Trimalleolar Ankle Fracture Treatment Like This

Question 8: My podiatrist performed closed treatment of a trimalleolar ankle fracture without manipulation. Which CPT® code should I report?

Answer 8: You should report code 27816 (Closed treatment of trimalleolar ankle fracture; without manipulation) for closed treatment of a trimalleolar ankle fracture without manipulation.