Question ORIF Trimalleolar fx

Merlin0728

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La Crosse Wisconsin Chapter
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We coded the following surgery as CPT code 27823 due to the posterior malleolar fragment being fixated. The insurance company is stating this should be 27822. We would appreciate any opinions on whether this should be 27823 or 27822.

Attention was first paid to the lateral malleolus. An incision was made centered over the fibula. Dissection continued through subcutaneous tissue to the fracture site was easily identified. A subperiosteal dissection was carried out around the fracture site as well as posteriorly to place the posterior antiglide plate. The fracture was easily reduced. A 7-hole 1/3 tubular plate from the Stryker system was placed in a posterior antiglide position. Six of the 7-screw holes were filled with the 4 proximal screws placed in nonlocking fashion and the 2 distal screws placed in locking fashion.

Attention was then paid to the medial malleolus fracture. An anterior medial incision was made centered over the fracture site at the medial malleolus. Dissection continued through subcutaneous tissue to the medial malleolar fracture, which was easily identified. A subperiosteal dissection was carried out at the fracture site as well as an anterior medial arthrotomy, so that the fracture reduction could be seen under direct visualization. Once the fracture was anatomically reduced. One guide pin from the Synthes screw set was placed. Once this was in appropriate position, a 46 mm screw was placed into the medial malleolus. This resulted in anatomic fixation both by direct visualization and by fluoroscopic evaluation. The joint surface appeared anatomically reduced and the medial clear space was normal.

Attention was then paid to the posterior malleolar fragment. It seemed to be anatomically reduced without an additional dissection necessary. It did seem to involve right around 20% to 25% of the surface. Because he initially was subluxed posteriorly, I thought it was probably important to fix this piece. Therefore, 1 guide pin for the 4.0 mm screw set from Synthes was placed. Once this was in appropriate position with the fracture anatomically reduced, a 46 mm screw was placed with a washer.

At the completion of the procedure, all hardware was in good position. All fractures were anatomically reduced and the ankle mortise was anatomically reduced. There was no increased medial clear space or any suggestion of disruption of the syndesmosis.

Thank you for any advice for coding this surgery!
 

Orthocoderpgu

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Salt Lake City, UT
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Sounds like your going to need to appeal. I would print out the op note and underline the note where the posterior lip was performed. So far I am virus free. Lucky enough to have my own office so I can keep the door closed and I avoid the patients.
 

Merlin0728

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La Crosse Wisconsin Chapter
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The insurance denied both the professional fee and the facility fee. We'll see what they do with the appeal.
Glad to hear you are doing well. I'm still working at the clinic. They are talking about sending us home to work.
We've been lucky with only 5 confirmed cases in our county so far.
 
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