Orthopedic Coding Alert

Question: My orthopedic surgeon performed an open reduction with internal fixation (ORIF) of an ankle fracture. The patient reported to the hospital nine weeks later with pain and fever. He had a wound infection and partial dehiscence. The surgeon did not do any additional procedures but admitted him for two days of IV antibiotics. Can I bill for this?

Wisconsin Subscriber

Answer: You could bill for the E/M inpatient service 99221-99223 for the first day of care, and use the subsequent hospital care codes (99231-99233) for the second day of care. However, if this is a Medicare patient, virtually the only postoperative care they will pay for is that involving a return to the operating room, so this would probably not be a reimbursed service.

Answers to You Be the Coder and Reader Questions provided by Heidi Stout, CPC, CCS-P, coding and reimbursement manager at University Orthopedic Associates in New Brunswick, N.J.