Wiki Ankle fractures

[nmendez1]

I need some assistance with some ankle fracture coding. In my experience I have always been told to code fractures based on diagnosis. So if there is a bimalleolar ankle fracture then you code with a bimalleolar CPT code. If it a trimalleolar ankle fracture then you use a trimalleolar CPT code. In the wording for these CPT codes it says "includes fixation, when performed" so this makes sense to me to use the code based on diagnosis even if both fractures do not get fixated with hardware. Lately we have been getting denials, mostly from UHC, saying that there is a more appropriate CPT code for some of our cases.

For example: Patient has a bimalleolar ankle fracture consisting of the lateral malleolus and the medial malleolus. The lateral malleolus is fixated, but the medial is not. This is still a bimalleolar ankle fracture. There was open reduction and internal fixation. So we coded with the 27814. The carrier is denying the 27814 saying there is a more appropriate CPT code.

I have talked to other coders and an auditor who agrees that this is coded correctly and that I am right to code these based on diagnosis. I was hoping to get other opinions and/or suggestions and see if anyone else has been having the same issues. Any comments are appreciated.

Thank you!

 

[amyjph]

You are correct. There is a CPT Assistant on this topic. While the CPT Assistant is addressing a syndesmosis injury with a bimalleolar, the answer still applies because it talks about reporting 27814 for fixation of only the lateral.

AMA CPT® Assistant - 2016 Issue 2 (February)​

Surgery: Musculoskeletal System (Q&A) (February 2016)​

February 2016 page 13a Surgery: Musculoskeletal System Question: A patient has a bimalleolar ankle fracture (lateral and posterior malleolus). A lateral fibular plate is used for repair of the lateral malleolar fracture. A reduction is performed, but no fixation is needed to repair the posterior malleolar fracture. A cotton test indicates widening of the syndesmosis; therefore, reduction of the syndesmosis is performed and two screws are placed through the fibular plate. Is it appropriate to report code 27829 in addition to code 27814 in this case? Answer: It would be appropriate to report CPT code 27814, Open treatment of...

What you have is an auditor and/or an automated edit who doesn't understand the coding and trying to deny. They are trying to get you to downgrade the code to 27792 which is incorrect. if you report 27792 with the bimalleolar diagnosis it would probably get denied too for the diagnosis not matching up with the CPT (lol). You definitely want to appeal and use the CPT description and the CPT Assistant reference. As long as it was coded correctly the first time with the correct diagnosis, etc. You would also want to submit the op report and double check the wording.

It's maddening for what is one of the most basic and frequent ortho CPTs.