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Orthopedic Coding Alert

Reader Question:

Bill Separate Incision for Syndesmosis Repair

Question: Our surgeon did the following procedure:Removal of internal fixation, right ankle.Open reduction and internal fixation of right distal fibula with a Arthrex periarticular distal fibular plate.Open reduction and internal fixation of one of the medial malleolus with an Arthrex medial hook plate and three syndesmosis repair with an Arthrex TightRope.Open reduction and internal fixation of bimalleolar ankle fracture.The patient was explicitly instructed to be nonambulatory on the right lower extremity secondary to her right ankle fracture as well as her recent medial tibial plateau stress fracture, which was treated by another orthopedic surgeon. She was noncompliant and was ambulating full weight bearing due to her deconditioning of her upper extremity and obesity. She was seen in the office where it was shown to have complete disruption of the internal fixation. She was admitted to the hospital and was taken to the operating room for above-mentioned procedure.The operative note reads [...]

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