phillirk
Guest
My surgeon thought we could only code for the tibia, CPT 27824. Am I able to code for both fractures? Do I need to use a modifier since the patient was seen elsewhere prior?
POSTOPERATIVE DIAGNOSIS: Right tibia Salter-Harris I displaced fracture and a segmental fibular fracture.
PROCEDURE PERFORMED: Closed manipulation and long leg casting of right distal tibia and fibula fracture.
INDICATIONS FOR PROCEDURE: Male sustained a significant 100% displaced tibia Salter-Harris I fracture of a tibial plafond and a segmental fibula fracture. He was close reduced elsewhere the night of the injury and had incomplete reduction. He presents today for reduction and casting.
DESCRIPTION OF PROCEDURE: Patient was brought into operating suite where general anesthetic was performed. His split was removed. His skin was intact. He was mildly swollen. A gentle longitudinal traction was performed with a little bit of varus force to the foot and inversion. This gave a much better alignment of his distal tibial physis. A well molded short leg plaster cast was applied. He was still in slight valgus and his fibula approximation was good but also in more of a bayonet apposition. It was felt that since he had a previous reduction a few days prior that further attempt at reduction would have a deleterious effect on the grown plate. This cast was then made into a long leg cast. The patient was awakened….
Thank you.
POSTOPERATIVE DIAGNOSIS: Right tibia Salter-Harris I displaced fracture and a segmental fibular fracture.
PROCEDURE PERFORMED: Closed manipulation and long leg casting of right distal tibia and fibula fracture.
INDICATIONS FOR PROCEDURE: Male sustained a significant 100% displaced tibia Salter-Harris I fracture of a tibial plafond and a segmental fibula fracture. He was close reduced elsewhere the night of the injury and had incomplete reduction. He presents today for reduction and casting.
DESCRIPTION OF PROCEDURE: Patient was brought into operating suite where general anesthetic was performed. His split was removed. His skin was intact. He was mildly swollen. A gentle longitudinal traction was performed with a little bit of varus force to the foot and inversion. This gave a much better alignment of his distal tibial physis. A well molded short leg plaster cast was applied. He was still in slight valgus and his fibula approximation was good but also in more of a bayonet apposition. It was felt that since he had a previous reduction a few days prior that further attempt at reduction would have a deleterious effect on the grown plate. This cast was then made into a long leg cast. The patient was awakened….
Thank you.