Orthopedic Coding Alert

Hint: Nails and fixators are the best guides.

In the May issue of Orthopedic Coding Alert, we learned about selecting the codes for the closed fractures of the tibia. The tibia is also highly subject to open fractures as the trauma that causes the fractures also may disrupt the skin and the covering muscles and other tissues. In this issue, we shall review some important tips to appropriately report these open tibial procedures.

Why Open Fractures?

Open fractures in the tibial shaft are usually due to high-energy trauma. Such fractures are at an increased risk of infections and wound complications due to the contamination and devitalization of the soft tissues. So, besides fracture healing, the treatment is also directed at wound closure, infection prevention, restoration of stability, and return of function.

Look For the Nails and Implants

You would code 27758 (Open treatment of tibial shaft fracture (with or without fibular fracture), with plate/screws, with or without cerclage) when plates/screws are used to stabilize the open fracture of tibial shaft and 27759 (Treatment of tibial shaft fracture (with or without fibular fracture) by intramedullary implant, with or without interlocking screws and/or cerclage) when intramedullary implants are used.

Orthopedists use locked intramedullary nailing to improve functional recovery and limb salvage in tibial shaft fractures. Also be aware that plating is no longer the preferred approach, as intramedullary nailing and external fixation are associated with decreased technical difficulty, lower infection rates, and less damage to local soft tissues. "Plating of tibial shaft fractures, especially of open tibia fractures, is very rarely done anymore, as the preferred treatment is either intramedullary nailing or external fixation," says Dr. Bill Mallon, MD, medical director, Triangle Orthopedic Associates, Durham, N.C.

Example 1: Here's an operative scenario: "In a supine position with leg in 90 degree flexion, after closed reduction, a transpatellar skin incision in line with the central axis of the medullary canal and extending up to the tibial tuberosity, was made and entry point identified being near to the lateral tubercle of the intercondylar eminence.

The medullary canal was opened using a cannulated drill. After reaming, the ETN was inserted using the handle and slight rotational movements. The passage of the nail through the fracture site was monitored and the final position was confirmed using an image intensifier."

You would code 27759 (Treatment of tibial shaft fracture (with or without fibular fracture) by intramedullary implant, with or without interlocking screws and/orcerclage) for the intramedullary nailing for the tibial shaft fracture in this scenario.

Example 2: Here is another similar operative scenario: "Starting position was made just medial to the tibial tuberosity. The fracture was reduced and a guidewire was placed across the fracture site under fluoroscopic guidance.

Reaming was then done up to a 10 mm size nail. After measuring for the correct length of the nail, a 10 x 280 mm intramedullary nail was driven into the tibia across the fracture site. Interlocking screws were then placed through the nail proximally using the proximal screw guide. Distal interlocking screws were placed across the nail in a freehand manner, using fluoroscopic guidance."

You report code 27759 for this work. The fluoroscopy here may be reported with the nailing procedure. "According to CPT®, fluoroscopy is separately reportable (with 76000 (Fluoroscopy (separate procedure)......) if the surgeon dictates an interpretation report," says Heidi Stout, BA, CPC, COSC, PCS, CCS-P, Coder on Call, Inc., Milltown, New Jersey and orthopedic coding division director, The Coding Network, LLC, Beverly Hills, CA. "The interpretation report must be separate from the operative note and should be signed separately," says Bill Mallon, MD, medical director,Triangle Orthopedic Associates, Durham, N.C. But, an intraoperative fluoroscopic interpretation by the operating surgeon is often not paid separately, adds Heidi.

Fixators Fetch You Payment

External fixation is another option your surgeon may use in some tibial shaft fractures. Here the orthopedist uses multiple pins attached to the external rods to maintain length and alignment of the tibial shaft. External fixation is preferred for severely comminuted fracture that is difficult to align for reaming and nailing or where the intramedullary canal is too narrow to ream.

Example: If the operative note states 'debridement and irrigation of the open wound is done and three Schanz screws are placed above and below the fracture site. Two bars are placed between the proximal and distal screws to compete the external fixation,' you would be wrong to report code 27758. "The fracture was not directly exposed," says Mallon. "Open fracture does not equal open treatment," warns Stout. "Reporting a debridement is now a highly scrutinized service. Documentation should mention contamination or devitalization of tissues when present and the surgeon must state the depth of tissue debrided," adds Stout.

In this situation, you would report codes 11010 (Debridement including removal of foreign material at the site of an open fracture and/or an open dislocation (eg, excisional debridement); skin and subcutaneous tissues), 11011 (Debridement including removal of foreign material at the site of an open fracture and/or an open dislocation (eg, excisional debridement); skin, subcutaneous tissue, muscle fascia, and muscle), or 11012 (Debridement including removal of foreign material at the site of an open fracture and/or an open dislocation (eg, excisional debridement); skin, subcutaneous tissue, muscle fascia, muscle, and bone) depending upon whether the debridement was deep to the subcutaneous tissues, muscles, or bone. You code 20690 (Application of a uniplane (pins or wires in 1 plane), unilateral, external fixation system) for the external fixator and if the fracture was reduced when the fixator frame was applied, you report code 27752 (Closed treatment of tibial shaft fracture [with or without fibular fracture]; with manipulation, with or without skeletal traction) for the fracture reduction.