Wiki triplane distal tibia fracture

[CCANTER]

i am needing help with cpt code for the fracture treatment of a triplane distal tibia fracture

1. my first thought is it was done percutaneously and would i use unlisted 27899? it is the only code i can come up with for percutaneous fixation of the distal tibia
2. or is it considered open due to incision and i would use 27827

this is the procedure

We used a 2-point tenaculum to try to reduce the fracture using live mini fluoroscopy. Percutaneously, we stabilized the fracture and reduced it with a 2-point tenaculum. We then used a 3.5 cannulated screw from the TriMed ankle set to place a screw obliquely across the fracture in the distal tibia intraarticular, but also parallel with the joint surface. Once the guidewire had been placed using live fluoroscopy, we pre-measured, pre-drilled, and then placed that screw to compress the diastasis within the joint.

I then placed a second screw anterior to posterior, again using a small incision to avoid any neurovascular complications or impingement of tendons. Once we got down to the bone with retractors, we placed the guidewire using live fluoroscopy, measured it, drilled it, and then placed it with a washer to compress the posterior fracture. Rigid anatomic reduction appeared to be obtained.

 

[NRaizman]

Anytime they say they dissected through subcutaneous tissue, or past tendons, or down to bone, or to avoid neurovascular structures, per CPT definitions of open treatment, this is ORIF.

In the future, I would ask your surgeons to be a bit more explicit, otherwise they risk losing money for the work they did.

 

[amyjph]

It says small incision, down to bone, and bone retractors in the last sentence you have there. Agree, the op note could be better if this is the whole thing. Was anything else done during the case?

 

[CCANTER]

thank you. No that was the only thing done and is the whole op note.