Inpatient Facility Coding & Compliance Alert

Question:  Our surgeon stabilized a pilon fracture using an external fixator and operated to fix the fibular fracture. After two weeks, an internal fixation was done. Can we report both the external and internal fixation procedures for this patient?

Ohio Subscriber 

Answer:  Your surgeon initially has used an external fixator for the tibia and an internal fixator to stabilize the fibular fracture. In this case, you report code 27826 (Open treatment of fracture of weight bearing articular surface/portion of distal tibia [e.g., pilon or tibial plafond], with internal fixation, when performed; of fibula only) for the open repair of the fibular fracture and placement of the external fixator for the tibia. 

Depending upon the type of fixator (uniplane or multiplane), report either 20690 (Application of a uniplane [pins or wires in oneplane], unilateral, external fixation system) or 20692 (Application of a multiplane [pins or wires in more than 1plane], unilateral, external fixation system [e.g., Ilizarov, Monticelli type]). Submit 27827 (Open treatment of fracture of weight bearing articular surface/portion of distal tibia [e.g., pilon or tibial plafond], with internal fixation, when performed; of tibia only) with modifier -58 (Staged or related procedure or service by the same physician or other qualified health professional during the postoperative period) for the internal fixation of the tibial fracture that was done after two weeks. In addition to code 27827, you’ll also report 20694 (Removal, under anesthesia, of external fixation system) for removal of the external fixator.

Documentation tip: Educate your physicians about the importance of documenting prospectively that the initial procedure might be followed by a subsequent or staged procedure. That physician note helps support the services rendered and your use of modifier 58.