Need some assistance. Dr performed an ORIF of the Rt lateral mallelous fracture and also a closed treatment of the right medial malleouls fracutre. He coded a 27814 which is a ORIF of bimalleolar fracture.
My question is can he do that? I mean he only performed an ORIF on the lateral side and a closed treatment on the medial side. Here is the op report:
Description of procedure: The patient was identified in the preoperative holding area. Surgical site marked. She was then brought back to the operating room, placed supine on the operating table. General anesthesia induced. Preoperative antibiotics given.A time-out was performed. The right lowe extremity was then prepped and draped in the standard surgical fashion and exsanguinated using esmarch with the tourniquet inflate to 350mmHg. We approached the lateral malleolus with a longitudinal midline incision over the distal fibula. Incision carried directly down to bone distally and proximally we took time to ensure that we did not injure the superficial peroneal nerve which was not encountered. We then dissected down to bone. We created two thick flaps of peristeum, anteriorly and posteriorly. We encountered fracture site which was debrided and curetted out and irrigated. We were able to see the fracture edges clearly. Then we reduced the fracture, brought it out to length using a lobster claw. We were able to visualize our anatomic reduction. We also checked an x-ray to make sure that the fibula is out to length. We were happy with our reduction which looked anatomic. We then used a lag technique and placed a 305 cortical screw to lag the two pieces together and hold it in place. We released our reduction clamp and the pieces stayed. We then placed an eight hole one third tubular plate as a neutralization plate over the lateral aspect of the fibula centered over the fracture site. We were able to get four screws distally and three screws proximally. We first secured the plate distally and then proximally and filled in the rest of the holes except for the one that was directly over the fracture site. We then took a final xray and we were happy with our fixation. Our ankle mortise remained anatomic. We then stressed the medial malleolus with external rotation which did not have any widening. Therefore, the decision was maded to treat the nondisplaced medial malleolus fracture closed without any fixation.
I am still fairly new at this but, cant I code these seperatly? 27792 and 27762
My question is can he do that? I mean he only performed an ORIF on the lateral side and a closed treatment on the medial side. Here is the op report:
Description of procedure: The patient was identified in the preoperative holding area. Surgical site marked. She was then brought back to the operating room, placed supine on the operating table. General anesthesia induced. Preoperative antibiotics given.A time-out was performed. The right lowe extremity was then prepped and draped in the standard surgical fashion and exsanguinated using esmarch with the tourniquet inflate to 350mmHg. We approached the lateral malleolus with a longitudinal midline incision over the distal fibula. Incision carried directly down to bone distally and proximally we took time to ensure that we did not injure the superficial peroneal nerve which was not encountered. We then dissected down to bone. We created two thick flaps of peristeum, anteriorly and posteriorly. We encountered fracture site which was debrided and curetted out and irrigated. We were able to see the fracture edges clearly. Then we reduced the fracture, brought it out to length using a lobster claw. We were able to visualize our anatomic reduction. We also checked an x-ray to make sure that the fibula is out to length. We were happy with our reduction which looked anatomic. We then used a lag technique and placed a 305 cortical screw to lag the two pieces together and hold it in place. We released our reduction clamp and the pieces stayed. We then placed an eight hole one third tubular plate as a neutralization plate over the lateral aspect of the fibula centered over the fracture site. We were able to get four screws distally and three screws proximally. We first secured the plate distally and then proximally and filled in the rest of the holes except for the one that was directly over the fracture site. We then took a final xray and we were happy with our fixation. Our ankle mortise remained anatomic. We then stressed the medial malleolus with external rotation which did not have any widening. Therefore, the decision was maded to treat the nondisplaced medial malleolus fracture closed without any fixation.
I am still fairly new at this but, cant I code these seperatly? 27792 and 27762