AR2728
Expert
I'm so confused on the appropriate CPT for this following procedure. What am I missing? Provider diagnoses: Comminuted fracture involving the mid diaphysis of the left fibula, 5 mm lateral and 5 mm posterior displacement of the free fracture fragment. As well as ankle syndesmotic Maisonneuve type injury.
Operative report reads as follows:
DIAGNOSIS:
Left ankle fibula fracture with syndesmotic injury
PROCEDURE PERFORMED:
Left ankle closed reduction and percutaneous pinning
....A small stab incision was made over the medial malleolus and lateral malleolus. Using a large reduction clamp, the synostosis was then reduced. At this point in time, 2, 3.5 mm fully threaded cortical screws were placed through the fibula into the tibia, getting all 4 cortices and holding the syndesmosis in place. The reduction clamp was removed. X-rays showed appropriate
reduction and hardware placement. At this point in time, tourniquet was let down and there was no significant bleeding. #3-0 Nylon suture was used to close the incisions.
10 cc's 0.25% Marcaine was injected into the incision site. A sterile, soft dressing was placed.
Operative report reads as follows:
DIAGNOSIS:
Left ankle fibula fracture with syndesmotic injury
PROCEDURE PERFORMED:
Left ankle closed reduction and percutaneous pinning
....A small stab incision was made over the medial malleolus and lateral malleolus. Using a large reduction clamp, the synostosis was then reduced. At this point in time, 2, 3.5 mm fully threaded cortical screws were placed through the fibula into the tibia, getting all 4 cortices and holding the syndesmosis in place. The reduction clamp was removed. X-rays showed appropriate
reduction and hardware placement. At this point in time, tourniquet was let down and there was no significant bleeding. #3-0 Nylon suture was used to close the incisions.
10 cc's 0.25% Marcaine was injected into the incision site. A sterile, soft dressing was placed.