Because orthopedists use many different terms to describe ankle fractures, coders should seek keywords in physician documentation to determine whether a fracture is bimalleolar, trimalleolar, medial malleolus or lateral malleolus.
Our physicians sometimes use terms in their documentation that don't exist in CPT " " says Deanna Bennett coder at the Milton S. Hershey Medical Center's Department of Orthopedics and Rehabilitation in Hershey Pa. "For instance if they use the term 'Weber B 'I know they're referring to a fracture in the distal fibula which is coded as a lateral malleolar fracture (824.2-824.3)." The orthopedist would use a procedure described in the 27786-27792 code range to treat this type of fracture.
Medial Malleolus: Direct talus impact or talus tension frequently causes these fractures so coders should look for the keywords "talus impact" or "talus tension" in the physician's notes. Some orthopedists may report a "tibial malleolar" fracture because the medial malleolus is at the end of the tibia.
If the orthopedist performs closed medial malleolar fracture treatment report either 27760 (Closed treatment of medial malleolus fracture; without manipulation) or 27762 (... with manipulation with or without skin or skeletal traction).
You should report 27766 (Open treatment of medial malleolus fracture with or without internal or external fixation) when the orthopedist uses an open method to treat the fracture. Report 824.0 (Fracture of ankle; medial malleolus closed) or 824.1 (Fracture of ankle; medial malleolus open) as the diagnosis.
Bimalleolar: When patients fracture both lateral (fibular) and medial (tibial) malleoli the orthopedist often refers to "Potts Fracture" or "Dupuytren Fracture" in his or her notes.
You should report 27808 (Closed treatment of bimalleolar ankle fracture [including Potts]; without manipulation) or 27810 (... with manipulation) if the orthopedist performs closed fracture care on a bimalleolar fracture.
When the orthopedist uses an open surgical method to treat the bimalleolar fracture report 27814 (Open treatment of bimalleolar ankle fracture with or without internal or external fixation) along with 824.4 (Fracture of ankle; bimalleolar closed) or 824.5 (Fracture of ankle; bimalleolar open) as the diagnosis.
The following is a sample operative report note for open bimalleolar fracture fixation: "Open reduction internal fixation of right ankle fracture of the fibula and tibia with chondroplasty of medial talar dome defect.
" Although this note initially appears more complex than 27814's description you should not report additional codes says Paul K. Kosmat-ka MD orthopedic surgeon at the Marshfield Clinic in Marshfield Wis. "The ankle arthrotomy debridement and removal of loose bodies are included in 27814 " Kosmatka says. "Unless the physician did something substantially different than just removing the [...]