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Need help with this surgery

  1. #1
    Default Need help with this surgery
    Medical Coding Books
    I am at wits end trying to come up with a code that my Ortho doc finds acceptable. Here is what was documented:

    1) left closed bimalleolar ankle fracture
    2)left closed distal tibia/fibular ligament sprain

    Procedures:
    1)Open reduction internal fixation left bimalleolar ankle fracture, medial and lateral
    2)closed reduction and internal fixation of left distal tibia fibular joint.



    I have 27814 for #1, but #2 stumps me. His OP report states "Her syndesmosis was seen widened therefore a large pointed reduction clamp was used to clamp the tibia and reduce the syndesmosis. A 3.5mm syndesmotic screw of length 52mm was placed across the fibula into the tibia.".
    I initially thought maybe this was a fracture, so I coded as 27756, but he said this wasn't fractured. I also can't use 27829, because he said it was a closed procedure.
    He said it was a ligament injury, but when I read the report, I can't associate anything being done to the ligament.

    Please help!!!!!


    Rich

  2. #2
    Location
    ENGLEWOOD/DENVER
    Posts
    2,338
    Default
    i dont think its truly closed, the patient is already opened for the bi-mall fx
    Mary, CPC, CANPC, COSC

  3. #3
    Location
    Seattle First Hill
    Posts
    126
    Default
    I agree with Mary, it doesn't sound like a closed procedure. How is he doing internal fixation if it is closed?

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