# Please - URGENT HELP NEEDED -Should it be a 27792 or  27814???



## maryir (Dec 7, 2017)

Hello everyone,

Please review the note below. I coded this as a 27792 but was told I was incorrect. 
I'm being advised to "correct" the coding to code the service as a 27814 (stating "Based upon review of op report, patient had B lateral malleolar fracture which was repaired medially and laterally"). 

I used a 27792 because the note is stating the patient had a bimalleolar equivalent fracture and an attempt was made to reduce it laterally but was unsuccessful. Am I looking at it wrong??

I have to either correct the code or be ready to defend my reasoning. 


PREOPERATIVE DIAGNOSIS:  Right bimalleolar ankle fracture.
POSTOPERATIVE DIAGNOSIS:  Right bimalleolar ankle fracture.
PROCEDURE PERFORMED:  Open reduction internal fixation of right bimalleolar ankle fracture.
IMPLANTS:  Synthes 1/3 tubular plate, 7 hole; and six 3.5 cortical screws.
**
INDICATIONS FOR PROCEDURE:  ...after he sustained a right bimalleolar ankle fracture approximately 10 days previous.  The patient states he was given a new splint on xx and was scheduled for surgery.  The patient was lost to followup prior to surgery and surgery had to be rescheduled but was able to be scheduled appropriately for xx.  On imaging, the patient had a *bimalleolar equivalent *right ankle fracture with an oblique fracture of the right lateral malleolus with widening of the syndesmosis.  It was discussed with the patient that given the character of the fracture pattern that his ankle was unstable and needed surgical fixation.  The patient was understanding and informed consent was signed.
**
PROCEDURE IN DETAIL:  The patient was identified in the preoperative area and the operative extremity was marked.  A regional block was placed by the anesthesia service in the right lower extremity.  The patient was brought into the operating theater and he was placed supine on the operating table.  General anesthesia was induced.  The patient was intubated.  The patient's splint was removed and the patient's right lower extremity was draped in the normal sterile fashion.  A timeout was performed and the procedure was begun.  Incision was made over the fibula down through subcutaneous tissues, careful to protect the superficial peroneal nerve.  This was brought down to the bone.  Fracture was identified.  Given the patient is approximately 3 weeks 
status post his injury, the fracture was noted to show signs of healing with some callus within the fracture itself. The fracture was booked open and the ends of the fracture were cleared out appropriately.  Reduction of the fracture was attempted; however, we were unable to get reduction that was of appropriate alignment.  We then moved to the medial aspect of the ankle.  An incision was made over the medial malleolus down to the level of bone.  
**
We moved our attention to the anterior aspect of the medial malleolus and cleared out the callus that was in the medial clear space area.  After this callus was appropriately removed, on imaging, we were able to more appropriately close down the medial clear space and his lateral malleolus fracture was more mobile.  Reduction was obtained and held in place by point-to-point clamp.  Alignment was confirmed using x-ray.  We then placed a 7-hole plate on the posterior aspect of the fibula and confirmed 
placement of the plate on x-ray.  The plate was held with an alligator clamp and the first 3.5 cortical screw was placed in buttress mode.  We then placed by lag by technique screws from posterior to anterior position through the fracture through the plate.  We used another clamp to keep the fracture appropriately compressed with the plate in place.  We then filled the remaining usable holes in the plate with cortical screws.  At this time, we then stressed the ankle and showed there is no opening and now had stabilization of the syndesmosis.  Both the medial and lateral wounds were appropriately irrigated and final images were taken.  
**
Deep fascia was closed with 0 Vicryl, subcutaneous tissue with 2-0 Vicryl and the skin with 3-0 nylon.  The patient was cleaned and was placed in a short leg splint.  
**
CONDITION:  The patient was awoken without any issues in the operating theater by anesthesia.  He was transferred to the PACU without any issues.


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## Chelle-Lynn (Dec 7, 2017)

Based on the documentation listed below I would have listed it as 27814.  During the 27814 procedure it is expected that during this procedure the physician realigns and sets an ankle fracture that shows under x-ray to be in any two of the three malleolar type bones -- medial, lateral, posterior. Due to the severity of the fracture, the physician must use an open approach to expose at least one of the malleolar bones to realign and secure the fragments such that the bone(s) can heal properly.


_After this callus was appropriately removed, on imaging, we were able to more appropriately close down the medial clear space and his lateral malleolus fracture was more mobile.  Reduction was obtained and held in place by point-to-point clamp.  Alignment was confirmed using x-ray_.


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## maryir (Dec 7, 2017)

Thank you for your response - but (and I apologize for my lack of understanding) I'm still a bit confused. 

If there was only one fracture (lateral malleolus fracture) and the rest of the surgery was for approach and wound repair, how does that meet 27814? - at best I was thing of charging for the widening of the syndesmosis but it's a CCI edit.


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## Ortho Coder  (Dec 7, 2017)

I would agree with 27792. You could put modifier 22 on the procedure for increased procedural services.  My thinking is he did not actually correct two fractures, only one.  27814 is for bi-mall.  Even though his approach was different than normal, he still reduced only the lateral mall.


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## AlanPechacek (Dec 7, 2017)

Regardless of the confusion, this was *Open Treatment of a Bimalleolar Ankle Fracture with Internal Fixation* (apparently only of the Lateral Malleolar Fracture), *27814*.  The Operative Report describes the opening and exposure of the Medial Malleolar Fracture with removal of healing callous and "mobilization" of the medial malleolus to allow the talus and lateral malleolus to reduce into satisfactory overall joint and fracture alignment.  This case is "confusing" to me as well, as I don't know why he did not also fixate the Medial Malleolus, but he apparently didn't (or he did but didn't document it).  The Descriptor for this code says "... includes internal fixation when performed."  This means that internal fixation of any or all of the fractures is not required to fulfill this code.

Hopefully this will help clarify some of this.  You may want to query your surgeon as to whether he did or did not internally fix the Medial Malleolus.  If he did in fact do so, then he needs to amend his Operative Report.

Respectfully submitted, Alan Pechacek, M.D.
icd10orthocoder.com


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