Orthopedic Coding Alert

Be sure your diagnosis specifies whether the fracture was open or closed.

Are you scratching your head when it comes to choosing the appropriate CPT^® code for ankle fractures? You’re not alone. With so many potential CPT^® codes to choose from, you need to differentiate between bimalleolar and trimalleolar open fracture repairs — because the mistake can cost your orthopedic practice precious dollars.

Orthopedists must be specific when documenting fracture repair because CPT^®’s index breaks down the ankle fracture codes into six types: lateral, medial, bimalleolar, trimalleolar, pilon/plafond or posterior malleolus.

Know Your Terms: When the site of the fracture is exposed to do a surgical repair, that’s referred to as an “open” treatment. Open treatment is used when the fractured bone is either surgically opened to visualize or fix the fracture, or is opened remote from the fracture site in order to insert an intramedullary nail across the fracture site.

If the fracture site is not surgically exposed to the external environment and directly visualized, it is referred to as a “closed” treatment. In a closed treatment the fracture is reduced without any exploration.

Question 1: How Do You Find the Correct Lateral Malleolus Fracture Code?

Answer: Even though CPT^® directs you to the 27786-27792 series for lateral malleolus fractures, your work may not be done because orthopedists don’t always dictate “lateral malleolus fractures” in their documentation. For instance, your orthopedist may document “distal fibula” fracture instead.

Next, you need to determine which surgical method the orthopedist performed: closed or open.

Closed: For closed fracture treatment of the lateral malleolus, report either 27786 (Closed treatment of distal fibular fracture [lateral malleolus]; without manipulation) or 27788 (… with manipulation). You would report 27786 for an application of a cast, CAM walker, splint, or orthosis. On the other hand, you would use 27788 when the fracture is displaced and needs to be reduced.

Open: If the orthopedist performs open treatment, report 27792 (Open treatment of distal fibular fracture [lateral malleolus], includes internal fixation when performed). Remember, open treatment means treatment of a fracture/dislocation by surgically exposing the fracture/dislocation site.

In some cases, physicians are treating the fracture with open reduction — actually seeing the fracture with the naked eye, not via X-ray — but they are placing the fixation percutaneously. You can still bill these as open treatment codes.

Question 2: What’s that Medial Malleolus Fracture Code?

Answer: Again, for medial malleolar fractures, you need to determine if the surgeon used a closed or open method.

Closed: If the orthopedist performs closed medial malleolar fracture treatment, report either 27760 (Closed treatment of medial malleolus fracture; without manipulation) or 27762 (... with manipulation, with or without skin or skeletal traction).

Open: You should report 27766 (Open treatment of medial malleolus fracture, includes internal fixation when performed) when the orthopedist uses an open method to treat the fracture.

New option: You may come across a physician treating medial malleolus fractures with closed manipulation and percutaneous fixation, but there is no CPT^® code for this procedure. Bill this method with an unlisted procedure code (27899, Unlisted procedure, leg or ankle). Be sure to include the op note, a description of the procedure, and a letter describing a comparable established procedure.

Question 3: Which of the 2 Bimalleolar Fracture Codes Should You Use?

Answer: You’ll note that CPT^® directs you to the 27808-27814 series in its index under both the “medial malleolus” and “lateral malleolus” listings. These codes actually represent bimalleolar fractures, which usually means the patient fractured both the lateral and medial malleoli. This could also mean lateral and posterior malleolus, or medial and posterior malleolus, though those are much more rare. Remember: Your orthopedist should document fractures of two of the malleoli, which can include the posterior malleolus.

Closed: You should report 27808 (Closed treatment of bimalleolar ankle fracture [e.g., lateral and medial malleoli, or lateral and posterior malleoli or medial and posterior malleoli]; without manipulation) or 27810 (... with manipulation) if the orthopedist performs closed fracture care on a bimalleolar fracture. You should look to S82.84-A (… bimalleolar fracture of … lower leg, initial encounter for closed fracture) as your diagnosis.

Open: When the orthopedist uses an open surgical method to treat a bimalleolar fracture, report 27814 (Open treatment of bimalleolar ankle fracture, [e.g., lateral and medial malleoli, or lateral and posterior malleoli, or medial and posterior malleoli], includes internal fixation, when performed) with S82.84-B (… bimalleolar fracture of … lower leg, initial encounter for open fracture type I or II) or S82.84-C (… bimalleolar fracture of … lower leg, initial encounter for open fracture type IIIA, IIIB, or IIIC) as your diagnosis.

Trap: If your physician sees a patient for a “bimalleolar equivalent fracture,” you may be tempted to report the bimalleolar fracture treatment codes for this injury. The AMA, however, advises you report either the lateral malleolus fracture treatment codes (27786-27792) or medial malleolus fracture treatment codes (27760-27766).

Note: A bimalleolar equivalent fracture is a fracture of either the medial or lateral malleolus with ligament disruption on the opposite side of the ankle — the most common being a lateral malleolus fracture with deltoid ligament disruption. This is usually a repair of the lateral malleolus with repair of the medial collateral ligament (deltoid) (27695, Repair, primary, disrupted ligament, ankle; collateral). This could also be repair/stabilization of the syndesmosis, which is 27829 (Open treatment of distal tibiofibular joint [syndesmosis] disruption, includes internal fixation, when performed).

Question 4: How Do You Find Correct Trimalleolar Code?

Answer: Trimalleolar fractures involve the same components as bimalleolar (medial and lateral) as well as the posterior lip of the tibia, which is termed the posterior malleolus for the purposes of this classification, although technically it is not a malleolus.

Closed: If the orthopedist performs a closed treatment, report 27816 (Closed treatment of trimalleolar ankle fracture; without manipulation) or 27818 (... with manipulation), with S82.85-A (… trimalleolar fracture of … lower leg, initial encounter for closed fracture) as your diagnosis.

Open: You should use 27822 (Open treatment of trimalleolar ankle fracture, includes internal fixation, when performed, medial and/or lateral malleolus; without fixation of posterior lip) or 27823 (... with fixation of posterior lip) for open trimalleolar treatments. Look to diagnosis codes S82.85-B (… trimalleolar fracture of … lower leg, initial encounter for open fracture type I or II), or S82.85-C (… trimalleolar fracture of … lower leg, initial encounter for open fracture type IIIA, IIIB, or IIIC).

Don’t miss: When the posterior lip does not require fixation, submit 27822. Otherwise, when the physician needs to address/fix the tibial posterior lip, you would report 27823.

Question 5: How Should I Report Pilon/Plafond Fx Codes?

Answer: You should look to codes 27824-27828.

Closed: When your orthopedist performs a closed method, you should report 27824 (Closed treatment of fracture of weight bearing articular portion of distal tibia [e.g., pilon or tibial plafond], with or without anesthesia; without manipulation) or 27825 (…with skeletal traction and/or requiring manipulation). Note: An external fixator is often applied for stabilization of a pilon fracture after closed reduction when future open treatment is planned, says Heidi Stout, BA, CPC, COSC, PCS, CCS-P, with Coder on Call, Inc., in Milltown, New Jersey.

Open: For the open method, you’ll look at 27826 (Open treatment of fracture of weight bearing articular surface/portion of distal tibia [e.g., pilon or tibial plafond], with internal fixation, when performed; of fibula only), 27827 (…of tibia only), or 27828 (…of both tibia and fibula).

Question 6: Where Are the Posterior Malleolus Fx Codes?

Answer: You already delved into codes covering treatment of medial malleolus fractures, but you should take into account the codes for posterior fractures.

Closed: When your orthopedist performs a closed method, you would report either 27767 (Closed treatment of posterior malleolus fracture; without manipulation) or 27768 (… with manipulation).

Open: For the open method, you should use 27769 (Open treatment of posterior malleolus fracture, includes internal fixation, when performed).