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Ankle fracture help! New to Ortho

  1. #1
    Default Ankle fracture help! New to Ortho
    Medical Coding Books
    Doctor states that this is a bimalleolar fracture; I need help with this please:

    Procedure Perfomed: Open reduction and internal fixation of left distal fibula and a fracture of one tibial plate in combination with cortical and cancellous screws.

    Procedure note in part: The fracture was identified and irrigated, and the fracture fragments were brought together with a lobster-claw clamp. After this, application of 8-hole plate was applied after forming it around the distal fibula, and a series of cortical screws were applied, 2.5 cortical screws proximally and distally 4.0 cancellous screws, stabilizing and securing the distal fibula.

    With this the fracture remained stable of the posterior malleolus, which was less than 20%, with the posterior syndesmosis and posterior tibia-fibula ligaments stabilizing the fracture. Scans in the AP lateral plan revealed the fracture to be stable under fluoroscopy.

    I'm not sure which code applies in this situation. With the documentation I have, it doesn't seem to support the codes for a bimalleolar fracture. I am totally new to Ortho, so I am sure that I am missing something. Any help is super appreciated. Thanks!
    __________________
    Jen Reyn Cert date 04/2007

  2. Default
    Hi there, I don't have the entire op report in front of me but I would be looking more at CPT code 29826 rather than the 27814 for bimalleolar..... hope that helps!

  3. #3
    Default
    I appreciate the response, but a 29826 is for arthroscopic decompression of the subacromial space, which is in the shoulder, I'm thinking you probably meant another code. But thanks for looking at it and responding. I'll keep searching.

  4. #4
    Default
    Hi Jen,

    I don't see any medial or posterior malleolar work - only the lateral malleolus has internal fixation applied in the documentation you've provided. If this is the note in its entirety, it looks like he only had to repair the lateral internally and he's left the medial fracture alone (or possibly manipulated only...the manipulation documentation isn't clear on what fragments were actually placed in the clamp). CPT 27814 says "Open treatment of bimalleolar ankle fracture (eg, lateral and medial malleoli, or lateral and posterior malleoli, or medial and posterior malleoli), includes internal fixation, when performed ". I would say you could bill this anyway...if this is what happened. I would say internal fixation doesn't have to be applied based on the code language "when performed". Billing the bimalleolar would still get your doc paid for his ORIF work on the lateral and also for assuming responsibility of the medial as well. Does that make sense?

    Kara Hawes, CPC

  5. #5
    Default
    Kara, yes, this was the whole op note, I just left out the prep notes. I understand what you are saying, and it does make sense. Thank you for your help. :0)

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