Corapeake, NC
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Good morning! I need some help in deciding if this is a Pilon Fx-27828- and ankle dislocation with IF-27848- (per what the doctor is requesting) or if this should be coded as a trimalleolar ORIF. I've gone back and forth with this any help or advice will be appreciate....below is the OP note.

16 cm longitudinal incision centered between the fibula and the achilles for a posteriolateral approach to the posterior malleolus. Skin was incised with a 15 blade followed by dissecting scissors to the peroneal muscles/tendons. The sural nerve was not encountered. The fascia to the flexor hallucis longus muscle was then incised and this muscle was then retracted medially to expose the posterior tibia. The fracture was identified and the periosteum was elevated to allow the fracture fragment to be gapped open to mobilize for reduction. This was a large articular fragment of the posterior tibia. The fracture was then reduced, with a good cortical read proximally, a k-wire was used to maintain reduction while verifying under fluoroscopy. At this point a posteriolateral tibial plate was selected and contoured appropriately. This plate was positioned over the apex of the fracture and held in place with k-wires. A bicortical screw was then placed in the apex hole with the plate under contoured to allow compression at the fracture. After verifying reduction, plate and screw placement with fluoroscopy, 2 screws were then placed in the distal plate and 1 more screw placed at the most proximal hole. Fluoroscopy was used to verify screw positions and lengths. The wound was irrigated with Irricept.

At this point, the fibula fracture was addressed. The peroneal tendons were retracted medially. Sharp dissection with a 15 blade carried down the posterior edge of the periosteum, elevating it to expose the fracture site and the lateral fibula.. Fracture hematoma was evacuated at the fibula fracture. We cleaned out some periosteal edges that would prevent anatomic reduction. There was severe comminution at the fracture site, which was located proximal to the plafond. A long fibular locking plate was selected to use as a bridge plate due to the fracture pattern and poor bone quality at the distal fibula. The plate was held in place with an olive wire and blunt reduction clamps. We checked AP mortise and lateral views of the ankle to ensure the fibula was out to length and was well reduced. Placed locking screws in the distal holes up to the fracture site. I then placed nonlocking screws in the proximal holes spaced out along the length of the plate. The reduction clamp and all of wires were removed and fluoroscopy demonstrated good placement of the plate good alignment of the fibula and good reduction.

I then proceeded with open reduction and fixation of the medial malleolus fracture. This fracture reduced nicely with reduction of the other fractures. The fracture blisters also placed the medial skin at risk so percutaneous fixation was necessary. Two guide wires for cannulated screws were placed and verified fluoroscopically. 2 partially threaded screws were then placed, gaining good compression across the fracture site. With all fractures fixed, I then obtained a mortise xray and performed an external rotation test as well as lateral pull on the fibula to test the syndesmosis. This was stable.
ORIF was performed both medially and laterally. A trimallor fracture is both of these with fixation of the posterior lip. Usually the posterior lip is fixed with a couple of screws. However, that's not what is documented. Your doctor put a plate on the posterior tibia. I'm wondering if this is how the pilon was repaired? If placing the posterior tibial plate corrected the pilon then it could be billed but I think your going to need to speak to him about that. I have coded dozens of pilon repairs and none of them read anything like this.