# Right distal tibia Salter-Harris II and distal fibula fracture at ankle closed treatment with manipulation - help with CPT



## KScoderTN (Sep 23, 2020)

I am looking at 27752 with both tibia/fibula,  I am also looking at 27788 distal fibula & 27825 for the salter harris ii distal tibia.  I appreciate any feedback.  Thank you in advance. 

PREOPERATIVE DIAGNOSIS:
Right distal tibia Salter-Harris II and distal fibula fracture at ankle.

POSTOPERATIVE DIAGNOSIS:
Right distal tibia Salter-Harris II and distal fibula fracture at ankle.

PROCEDURE PERFORMED:
Right distal tibia Salter-Harris II and distal fibula fracture at ankle closed treatment with manipulation.

SURGEON:

ASSISTANT: None.

ANESTHESIA: Sedation.

TOURNIQUET: See operative record.

BLOOD LOSS: None.

SPECIMENS: None.

COMPLICATIONS: None.

IMPLANTS: None.

INDICATIONS:

is a pleasant young gentleman who presented with a Salter-Harris II severely displaced distal tibia fracture as well as an associated distal fibula fracture at the ankle joint level. I recommended a closed reduction initially. I did discuss potential postreduction CT scanning and possible need for surgical intervention. The family wished to proceed with this.



Risks, benefits, and alternatives of the procedure were discussed with the patient at length. The alternative of conservative management with casting or bracing without reduction was discussed and the patient and family wished to proceed with surgical intervention. The expected outcomes of the procedure include improvement in alignment and healing. The expected postoperative course and rehabilitation were discussed with the patient, including the recovery and immobilization. Potential risks of the surgery include continued pain, malalignment, late loss of reduction, cast complications, decreased range of motion, and compartment syndrome. The patient understood the potential need for further surgical intervention in the future. All questions were answered. The patient and family gave their informed consent in written and verbal forms prior to the procedure.



DESCRIPTION OF PROCEDURE:

The patient was brought to the procedure area and placed supine on the table. A preprocedure timeout was completed confirming the correct patient, surgical site, and procedure. The patient was then sedated.



The knee was flexed, and the fracture was then accentuated in its deformity followed by traction and a reduction was undertaken. Fluoroscopy was utilized and confirmed in near-anatomic reduction. However, this required maintaining pressure. A short leg U splint with a posterior slab extending as a foot plate was then applied and held with the reduction. There was minimal residual displacement seen on the fluoroscopy after the reduction.



The patient tolerated the procedure well.



POSTPROCEDURE CONDITION: Stable.



DISPOSITION:

The patient was given written postoperative instructions. These included elevation and exposed digit range of motion. Signs to monitor for compartment syndrome were discussed with the patient and family. The patient must cover the dressing for showers until followup. The patient was also provided with a prescription for postoperative pain medication. A phone number was given to contact for any questions or complications prior to the follow-up appointment.


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## cclarson (Sep 23, 2020)

Since the doctor specifically states that they are distal fractures, I would go with 27788 and 27825. However, the body of the op note only states that he worked on one fracture, and doesn't state which. It's possible that by doing closed reduction on one, that it happened to resolve the other fracture as well. In that case, I would code a closed reduction for the fracture he worked on, and put both fractures as dx. So I would talk with the doctor for clarification. You need more support in the report, so an addendum may be needed.


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## KScoderTN (Sep 24, 2020)

cclarson said:


> Since the doctor specifically states that they are distal fractures, I would go with 27788 and 27825. However, the body of the op note only states that he worked on one fracture, and doesn't state which. It's possible that by doing closed reduction on one, that it happened to resolve the other fracture as well. In that case, I would code a closed reduction for the fracture he worked on, and put both fractures as dx. So I would talk with the doctor for clarification. You need more support in the report, so an addendum may be needed.



Thank you so much for your response.  I appreciate your help.


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