Podiatry Coding & Billing Alert

Hint: Remember to append modifier 58 for staged fixations.

If you ever come across “pilon fractures” in your podiatrist’s medical documentation, you must keep track of numerous details to keep these claims in tip-top shape. For example, you must know exactly which bones the podiatrist repaired, whether he made the repairs internally or externally, and if he performed any staged fixations.

Follow these five tips to navigate the pilon fracture claims in your podiatry office with ease.

Tip 1: First, Define Pilon Fractures for Clarity

A pilon fracture, also called a plafond fracture, is a fracture of the distal part of the tibia, involving its articular surface at the ankle joint. Pilon fractures are caused by rotational or axial forces, usually a result of falls from a height or car accidents.

Pilon fractures are complicated, comminuted fractures that have a poor long-term outcome, explains Jordan Meyers, DPM, partner at Raleigh Foot and Ankle Center and consultant at Treace Medical Concepts, Inc. in Raleigh, North Carolina.

Tip 2: Differentiate Between Closed and Open Treatment

You will choose from the following three codes when reporting an open treatment for a pilon fracture:

• 27826 (Open treatment of fracture of weight bearing articular surface/portion of distal tibia (eg, pilon or tibial plafond), with internal fixation, when performed; of fibula only)
• 27827 (… of tibia only)
• 27828 (… of both tibia and fibula)

Closed treatment: And for closed treatment of pilon fractures, you can report the following two codes:

• 27824 (Closed treatment of fracture of weight bearing articular portion of distal tibia (eg, pilon or tibial plafond), with or without anesthesia; without manipulation)
• 27825 (... with skeletal traction and/or requiring manipulation).

Tip 3: Carefully Check Medical Documentation

When choosing between codes 27826, 27827, and 27828, make sure to check the medical documentation and see which bones the podiatrist repaired.

For example, if the podiatrist performs internal fixation on only the fibula, you should report 27826. And, if the podiatrist performs internal fixation on only the tibia, you would report 27827.

Finally, if the podiatrist performs internal fixation on both the tibia and the fibula, you should report 27828.

Tip 4: Remember to Report External Fixators

Your podiatrist may use pins, screws, or wires to stabilize and align the reconstructed distal articular block to the metaphysis. The external fixator may span the ankle joint and incorporate the foot, although it may limit the ankle’s movements. The podiatrist may use an external fixator when the injury is an open fracture or if there is extensive fracture blistering present.

Also, your podiatrist may use an external fixator to incorporate and distract the talus. By doing so, the podiatrist is indirectly trying to restore the fibular length by applying traction on the fibula through the intact talofibular ligaments.

Example: You can separately report code 20690 (Application of a uniplane (pins or wires in 1 plane), unilateral, external fixation system) in addition to 27825 when the surgeon uses an external fixator to realign the fracture. You may report 20692 (Application of a multiplane (pins or wires in more than 1 plane), unilateral, external fixation system (eg, Ilizarov, Monticelli type)) if the surgeon uses a multiplane fixation system.

Tip 5: Don’t Overlook Staged Fixations

Pilon fractures may involve complex injuries and several fragments. Since trauma is the most common cause, there can be extensive soft disuse damage and swelling accompanying the fracture.

In this situation, the podiatrist may plan a temporary fixation on the day of the injury, followed by a more definitive fixation at a later date.

Take a look at this example from Arnold Beresh, DPM, CPC, CSFAC, in West Bloomfield, Michigan: The podiatrist fixes the patient’s fibula on the day of the injury and places a temporary external fixator to stabilize the tibia. Since the patient has severe swelling of tissue, this external fixator allows inspection of the soft tissue without frequent splint changes. No incision is made through the damaged tissue.

Two weeks later, the patient returns to the OR, and the podiatrist removes the external fixator and converts to internal fixation after the soft swelling has reduced. This second procedure was planned ahead of time.

Coding solution: The surgeon should report 27826 and 20690 on the first date of service followed by 27827 on the second date of service.

Don’t forget: You should append modifier 58 (Staged or related procedure or service by the same physician during the postoperative period) to 27827 because the podiatrist performed the initial fixation with the intent of returning to the OR to convert to internal fixation.