Orthopedic Coding Alert

Look to casts, nails, plates and fixators to guide your coding.

While tibial fracture coding can hinge on fracture type -- open or closed-- you'll need to know what was done to reduce the fracture and align the bone. Missing crucial details like whether screws, nails, plates, fixators were used or just a cast sufficed to immobilize the fracture can downgrade your full reimbursement for these services.

Incidence: Tibial fractures are a common consequence to high speed trauma. However, there can also be stress fractures due to repeated microtrauma of frequent activity. "Falls, sports injuries, vehicular accidents, and overuse are common causes of a broken leg," says Leslie A. Follebout, CPC, COSC, senior orthopaedic coder & auditor with The Coding Network, Beverly Hills, California.

Understand 'Fibular' in Descriptor

When you look at the codes for the fractures in the leg bones, you will see that these codes are mainly directed to the tibial shaft fractures and also mention 'with or without fibular fracture'. For example, when reporting a closed treatment for tibial shaft fracture, you would use the code 27750 (Closed treatment of tibial shaft fracture (with or without fibular fracture); without manipulation).

The tibia is the stronger and more prominent and superficial weight-bearing bone in the leg and is more likely to be broken, usually due to trauma. But it is not uncommon for tibial fractures to be accompanied by those in the fibula, the slender lateral bone in the leg. This is because the two are connected by an interosseous membrane that transmits the forces from one to another. "It is rather uncommon to find an isolated midshaft fibular fracture, unless there is a direct blow to the area," says Dr. Bill Mallon, MD, medical director, Triangle Orthopedic Associates, Durham, N.C. The codes for fractures in the shaft of the tibia are hence inclusive of fibular fractures.

Identify Closed vs Open Fracture Treatment

The term 'open' implies the site of the fracture was exposed to do a surgical repair and 'closed' implies that the fracture was reduced without any exploration. "Closed treatment implies that the fracture site is not surgically exposed to the external environment and directly visualized. Open treatment is used when the fractured bone is either surgically opened to visualize and fix the fracture or is opened remote from the fracture site in order to insert an intramedullary nail across the fracture site," explains Follebout.

Report code 27750 (Closed treatment of tibial shaft fracture (with or without fibular fracture); without manipulation) when a closed treatment was done without manipulation and 27752 (Closed treatment of tibial shaft fracture (with or without fibular fracture); with manipulation, with or without skeletal traction) when the surgeon manipulated the fracture to reduce it, irrespective of the use of traction. When the orthopedist inserts pins or screws through the skin to stabilize the fractured bone underneath, report code 27756 (Percutaneous skeletal fixation of tibial shaft fracture (with or without fibular fracture) (eg, pins or screws)). "Tibial fractures would be coded as 27750 for closed treatment without manipulation, 27752 for displaced fractures that require manipulation, 27756 for percutaneous fixation, 27758 for open treatment with plates and screws, or 27759 for fracture treatment by insertion of an intramedullary implant," says Follebout.

Identify How the Closed Fracture Was Reduced and Stabilized

Your orthopedist may use a cast when treating the closed fractures in the tibia and/ or fibula. You should carefully look for evidence supporting the use of a cast, the ideal candidate for which is a young patient with a non-displaced fracture.

Closed fractures with minimal displacement or stable reduction may be treated nonoperatively with a long leg cast, but cast application may be delayed for 3-5 days to allow the early swelling to diminish. The long-leg cast extends from the mid thigh to the metatarsal heads, with the ankle at 90 degrees of flexion and the knee extended. The cast increases tibial stability and can decrease pain and swelling. The orthopedist may do close monitoring with frequent radiographs to ensure that the fracture has maintained adequate alignment. Adequate callus formation usually takes 6-8 weeks before casts are removed. "However, this is variable, and cast removal is usually dependent on X-ray appearance of the fracture and clinical exam of the patient, and the surgeon may elect to place a shorter cast before discontinuing immobilization altogether," says Dr. Mallon.You report code V54.16 (Aftercare for healing traumatic fracture of lower leg) for the shorter cast as it forms a part of the aftercare for the fracture.

Example: If you read 'After compartment syndrome was ruled out, the orthopedist stabilized the fracture in the distal shaft of the tibia using a patellar tendon bearing cast and advised immobilization,' the correct code here would be 27750 (Closed treatment of tibial shaft fracture (with or without fibular fracture); without manipulation) or 27752 (Closed treatment of tibial shaft fracture (with or without fibular fracture); with manipulation, with or without skeletal traction), depending upon whether or not reduction was performed. Splint or cast application is inclusive to the global fracture treatment codes 27750 and 27752," advises Heidi Stout, BA, CPC, COSC, PCS, CCS-P, Coder on Call, Inc., Milltown, New Jersey and orthopedic coding division director, The Coding Network, LLC, Beverly Hills, CA. If, however, the splint was used to provide protection to and facilitate skin healing so as to enable a future open reduction and internal fixation (ORIF), the closed reduction codes are not used and you may report 29515 (Application of short leg splint (calf to foot)) for the leg splint.

Similarly, you would report code 27750 if you read 'Under conscious sedation in a spiral fracture in tibialshaft with initial shortening of 10 mm and angular deformity of 5 degrees, an above-knee cast was applied that held the knee in 100 or less flexion and the ankle in a neutral position.' "You do not code for the cast unless the cast is being applied as a temporizing measure until surgery is performed," says Stout.

However, not all closed fractures can be treated nonoperatively. The surgeon may do an operative fixation in a closed fracture if the fracture is an unstable one, or if the patient and physician elect to treat the fracture surgically. This is more likely in fractures that are along the length in the tibia, are accompanied by fractures in the fibula in the same leg, and are communited. This may be preferred when there is more than 1.5 cm of shortening, greater than 5 degrees of varus or valgus angulation, 5 degrees of anterior or posterior angulation, and/or less than 50% translation while the leg is in a cast. "In 2011, more and more midshaft tibia fractures are treated operatively, usually with an intramedullary nail, and cast treatment is becoming less and less common," says Dr. Mallon.

Example: Here's a possible operative scenario for external fixation. "A large adjustable fixator was secured using the 6-position drill guide handle and drill sleeves to insert Schanz screws perpendicular to the bone and in line with the axis of the bone. The fixator was applied by sliding the pin clamp over Schanz screws in the proximal fragment and tightening the pin locking screws ensuring that all adjustable screws have an easy access. Schanz screws were then inserted through the distal fragment and reduction handle used for additional leverage. The fixator was locked in position." For this procedure, you would report 27752 along with 20690 (Application of a uniplane(pins or wires in 1 plane), unilateral, external fixation system) for the fixator.