Chris Posted Wed 05th of June, 2019 14:58:20 PM
PreOP & Postop note: Left ankle pilon fracture, left ankle fibular fracture, and left ankle syndesmotic rupture. Procedure Let ankle open reduction of the pilon fracture with internal fixation. Fibular fracture with open reduction and internal fixation. Syndesmotic repair with internal fixation. Below the knee cast application. After mild sedation, the patient was brought to the operating room, placed on the operating table in supine position. Following IV sedation, the left foot and leg were scrubbed, prepped, and draped in usual aseptic manner. Left thigh tourniquet was then placed and inflated. At this point, attention was directed to the lateral aspect of the left ankle, where a longitudinal incision was made and carried down through subcutaneous and deep tissue to the level of the fibular fracture. Care was taken to identify the superficial peroneal nerve and retract it. At this point, we were able to visualize the transverse fracture of the high fibula. We were unable to get the fibula back to length, so we used a distracter and we pinned both sides of the fibula and we distracted it back to length. As we did that, we put a 12-hole plate, 1/3 tubular, to span it. Intraoperative x-ray was taken to ensure good spanning of the fibula and it was. At this point, attention was directed to the anteromedial aspect of the ankle where the pilon fracture is. A longitudinal incision was made and carried down through subcutaneous and deep tissue to the level of the hematoma that was noted. We noted the skin was tented at this point here and the soft tissue envelope was pretty bad. The hematoma was evacuated and at this point, we were able to connect the medial to lateral incisions and see the whole pilon from anterior to posterior and medial to lateral. Using a distracter again, we were able to distract the distal aspect of the tibia and the talus and were able to rebuild the pilon using interfrag screws that are 4-0 cannulated screws. At this point, we noted that the fibula is in place and the tibial plafond is in place. The ankle mortise was established with separation of the syndesmotic membrane. So, we were able to clamp both tib-fib complex and we took the 4th screw out from the plate and we inserted a syndesmotic screw, which is a 50 mm 3.5 cortical screw, crossing all 4 cortices closing down the syndesmotic. At this point, to hold the whole pilon in place, we put an anteromedial plate and we spanned all the fracture fragments with 3.5 cortical screws. Wound was flushed with normal saline over and over. The intraoperative x-ray was taken to show good positioning and once the ankle was taken through its range of motion and it was smooth, deep tissue was reapproximated using 2-0 Vicryl, followed by subcutaneous tissue reapproximation using 4-0 Vicryl, followed by skin reapproximation using skin staples. Wound was covered with Xeroform, 4 x 4, Kerlix, cast padding, and below-the-knee cast application was applied. Patient tolerated the above procedure well without any complication and transferred from operating room with vital signs stable and vascular status intact to all the digits of the left foot.
Following a short period of postoperative monitoring, the patient will be discharged home with oral and written postoperative instructions.
We came up with 27828 and 27829 - doctor says it is wrong, there should be 4 codes including billing for the cast. He wants us to start billing for 'cast' with all his procedures (when done). can you please advise on this surgical note and about the casting. Thank you
SuperCoder Answered Thu 06th of June, 2019 04:19:10 AM
Chris Posted Thu 06th of June, 2019 16:54:36 PM
Thank you but I was not expecting you to 'code' the chart, I already came up with the codes. I just need them verified by an 'expert' per the doctors request. Also needed an answer toward the end of the chart about casting. We told him no casting since he did an OPEN procedure but he wants to bill for it. Are you in agreement with that? I believe that is what CPT says but he still wants us to 'ask the expert.' I feel somewhat 'cheated' here because we paid for 'ask the expert' and this question used one (1) of my 5 questions we paid for, but we really got no response other than "AAE does not provide coding for operative reports and chart notes."
SuperCoder Answered Mon 10th of June, 2019 07:10:29 AM
Thanks for your question.
This is our defined process; this platform is for Ask An Expert (AAE) queries and it does not provide coding/reviewing of op-reports. Since, you have provided the complete report, we have to take up this through SuperCoder on Demand (SOD) (http://www.supercoder.com/coding-answers/coding-on-demand).
On your query of cast; the casts, splints and straps are immobilization devices applied to protect injured bones and soft tissue and to reduce pain, spasm, and swelling following a surgery. In CPT 27828 and 27829 (open treatment of fracture), the provider closes the wound and applies a cast or brace to help stabilize the fracture. He may take post treatment X–rays to ensure correct alignment. Hence, cast need not to be billed separately. As per guidelines, application of these devices is often part of a global surgery. In that case, casting is part of the global charge.
If you still want us to go through the op-report, send it to our defined channel i.e. SuperCoder on Demand (SOD). Kindly mention that you have already placed the op-report in the AAE and direct it to medical coding team.
Looking forward to serving you well.