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Ankle Fracture

  1. #1
    Default Ankle Fracture
    Medical Coding Books
    Totally stumped on this one.....Operative report reads, "The tibia was extruded medially with a transverse laceration over a small laceration running proximally. A fracture was noted involving the medial malleolar area, this was reduced anatomically, held in place with 2 guidewires. Over the guidewires, the bone was then drilled, and the appropriate length 4.0 mm diameter partially threaded screw was then utilized and stabilized in the medial malleolus to the distal tibia.

    Starting laterally, a longitudinal incision was performed. Dissection was carried down to the comminuted fracture involving the distal third of the fibula. A fibular locking plate was applied and so on....

    Would this be coded as an ORIF of a bimalleolar fracture? Not sure because operative report never mentions lateral malleolus.

    Thanks for any input!

  2. #2
    I would use ORIF of a bimalleolar fracture because he states distal fibula which usually means lateral malleolus. This is what I have found with the doctors I work with.

  3. #3
    You might want to confirm the fib fx as some physicians will consider distal/prox third as shaft. Just a thought

  4. #4

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