Orthopedic Coding Alert

If you limit 27808-27814 to lateral and medial malleoli fractures, you-re risking errors on your claims. Clear up the confusion with this look at all the bimalleolar and trimalleolar CPT and ICD-9 details.

If a patient has a bimalleolar fracture, she has fractured two malleoli (rounded protuberances on each side of the ankle), as the examples in 27808-27814's code descriptors indicate:

- 27808 -- Closed treatment of bimalleolar ankle fracture (e.g., lateral and medial malleoli, or lateral and posterior malleoli, or medial and posterior malleoli); without manipulation

- 27810 -- - with manipulation.

- 27814 -- Open treatment of bimalleolar ankle fracture (e.g., lateral and medial malleoli, or lateral and posterior malleoli, or medial and posterior malleoli), includes internal fixation, when performed.

You probably see lateral and medial bimalleolar fractures most often, but including posterior malleoli in the description simply describes a less common possibility, explains Shelly Ghrist, CPC, assistant manager of Wolf Creek Medical Associates in Pennsylvania.

CPT added the examples to the descriptors in 2008. The change is helpful because CPT didn't spell out which code to use for a bimalleolar fracture involving the posterior malleolus before, Ghrist says.

And, according to the AMA's CPT Changes 2008, that was the revision's intent -- "to describe all patterns and combinations of bimalleolar fractures and to assist in accuracy of code selection."

As the descriptors also indicate, you should choose 27808 and 27810 for closed bimalleolar treatment.

But, you may be more likely to see the surgeon choose open reduction, internal fixation (ORIF) for bimalleolar fractures, says Chris Ford with the billing department of Coastal Orthopedics and Sports Medicine Group in Oceanside, Calif.

You should report this bimalleolar ORIF procedure with 27814, notes Ford, who frequently sees this treatment at her practice.

27814 tip: CPT 2008 adjusted the 27814 descriptor to state "includes internal fixation when performed" to clarify that the code includes internal fixation, but you may report external fixation separately (20690-20692), states CPT Changes 2008.

To prove medical necessity for 27808-27814, payers require you to submit an appropriate diagnosis code. The codes describing bimalleolar fractures are 824.4 (Fracture of ankle; bimalleolar, closed) and 824.5 (Fracture of ankle; bimalleolar, open).

Pott's change explained: Before the 2008 CPT change, the 27808 and 27810 descriptors stated, "Closed treatment of bimalleolar ankle fracture (including Potts) -"

You may not see the term Pott's very much any more, but it is a type of bimalleolar fracture, explains Ford. So even though CPT removed the term "Potts" from the 2008 CPT code descriptors, you should still report 27808 or 27810 if the surgeon documents closed treatment of a Pott's fracture (824.4).

Other synonyms: A note with 824.4 in the ICD-9 manual adds another older term, Dupuytren's fracture, to the bimalleolar mix: "Dupuytren's fracture (Pott's fracture): The breaking of the farthest end of the lower leg bone (fibula), with injury to the farthest end joint of the other lower leg bone (tibia)."

Your surgeon may use other terms to refer to bimal-leolar fractures, as well. Example: The lateral malleolus is fibular and the medial malleolus is tibial, so the operative report may refer to a distal fibula fracture instead of a lateral malleolus fracture.

Consider this example: If the surgeon performs an ORIF procedure for a patient with an open medial malleolus and distal fibular fracture, you should report 27814 linked to 824.5.

While bimalleolar fractures involve two (bi-) malleoli, trimalleolar fractures involve all three (tri-).

In other words: Trimalleolar fractures involve the lateral and medial malleolus with the anterior or posterior tibial lip, according to a note with 824.6 (Fracture of ankle; trimalleolar, closed) in the AMA version of the 2008 ICD-9 manual.

Term tip: The reality is you-re unlikely ever to see the term "anterior lip" appear in an op note. But if you see the term "posterior lip," you should know it's interchangeable with "posterior malleolus."

So, the surgeon may document a "bimalleolar ankle fracture repair, with repair of the posterior malleolus," but this is simply a trimalleolar fracture repair.

You also may see the term "lip fracture."

Remember to report the fracture using either 824.6 or 824.7 (Fracture of ankle; trimalleolar, open).

You should choose the appropriate trimalleolar CPT code based on closed or open treatment. If the surgeon performs a closed trimalleolar treatment, you should report 27816 (Closed treatment of trimalleolar ankle fracture; without manipulation) or 27818 (... with manipulation).

You should use 27822 (Open treatment of trimalleolar ankle fracture, includes internal fixation, when performed, medial and/or lateral malleolus; without fixation of posterior lip) or 27823 (... with fixation of posterior lip) for ORIF trimalleolar treatments, Ford says.

For example: If the surgeon performs closed treatment with manipulation of a closed trimalleolar fracture, you should report 27818 linked to 824.6.

Don't forget: Codes 27822 and 27823 also got an update in 2008, similar to 27814, changing "with or without internal or external fixation" to "includes internal fixation, when performed." So you may report external fixation separately with these codes.