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Coding help - salter harris ii distal tibial fracture

  1. #1
    Flint, MI
    Default Coding help - salter harris ii distal tibial fracture
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    Patient has a distal tibial fracture, Salter Harris II

    I've looked at lots of pictures of this type of fracture, read through the classifications, etc.

    Want opinions on what DX code you would use

    Also, since doc did and ORIF of the fracture, which CPT code would you use?

    Thanks in advance

  2. #2
    HOI Peoria, IL Chapter
    Default Dx code
    Salter Harris II is a type of fracture. You need to find out what part of the bone is fractured. Medial or lateral malleolus or Bimalleolar or Trimalleolar and choose your code from there. They start at 8240 - 8249.

    As for the procedure code you need to choose which one best fits the part of the bone that is fractured. I would start at 27808 and go from there.

    I wish I could help further but without the op report I can only sent you to certain sections.

    I hope I was helpful.


  3. #3
    Greater Pittsburgh
    I agree that it is a type of fx and as if you state a distal tibia fx is 824.8 closed fx or 824.9 open fx without any further detail.
    jdemar, CPC, CMA

  4. #4
    Flint, MI
    Thanks all. Unfortunately my docs rarely tell me more than this. Very frustrating.

    Happy coding!

  5. Default Salter-Harris II fx
    Salter-Harris is a type of fracture, but I think there is enough information. If you look at the Salter-Harris Classification table, you can see that a type II fx is a fracture that breaks through part of the bone at the growth plate and crack through the bone shaft as well. I think this is enough information to comfortably choose a CPT code for the tbial shaft. Now from there you may need more information as far as what kind of fixation was used. 27758, 27759. You can find the information on the classification table on the AAOS website.

  6. #6
    These fractures are typically not unstable. ORIF can cause further insult to the epiphysis. A single malleolar lag screw would be the norm. You may want to look at SER ankle fx code since the tib/talus joint is involved.

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