Orthopedic Coding Alert

Mistaking bimalleolar and trimalleolar fracture codes? If so, you could be costing your practice almost $100 -- the difference in reimbursement between the open repair codes for these ankle fractures.

Orthopedic surgeons must be specific when documenting fracture repair because CPT's index breaks down the ankle fracture codes into five types: lateral, medial, bimalleolar, trimalleolar, or posterior malleolus.

Important: -The fracture itself can be an open fracture (puncture through the skin at the time of the injury) or closed (no break in the skin),- says Ruby Woodward,BSN, ACS-OR, coding and research specialist for Twin Cities Orthopedics in Minneapolis, Minn.

Even though CPT directs you to the 27786-27814 series for lateral malleolus fractures, your work may not be done because surgeons don't always dictate -lateral malleolus fractures- in their documentation. For instance, your orthopedist may document -distal fibula- fracture instead.

Next, you need to determine which surgical method the orthopedist performed:closed or open.

Closed: For closed fracture treatment of the lateral malleolus, report either 27786 (Closed treatment of distal fibular fracture [lateral malleolus]; without manipulation) or 27788 (- with manipulation). -You would report 27786 for an application of a cast, CAM walker, splint, or orthosis,- Woodward says. On the other hand, you would use -27788 when the fracture is displaced and needs to be reduced.-

Open: If the surgeon performs open treatment, report 27792 (Open treatment of distal fibular fracture [lateral malleolus], includes internal fixation when performed). -Open treatment means treatment of a fracture/dislocation by surgically exposing the fracture/dislocation site,- says Kathleen F. Nelson, CPC, orthopedics professional coder at Fletcher Allen Health Care in Burlington, Vt.

-In some cases, physicians are treating the fracture with open reduction -- actually seeing the fracture with the naked eye, not via x-ray -- but they are placing the fixation percutaneously. You can still bill these as open treatment codes,- Woodward says.

Again, for medial malleolar fractures, you need to determine if the surgeon used a closed or open method.

Closed: If the orthopedist performs closed medial malleolar fracture treatment, report either 27760 (Closed treatment of medial malleolus fracture; without manipulation) or 27762 (... with manipulation, with or without skin or skeletal traction).

Open: You should report 27766 (Open treatment of medial malleolus fracture, includes internal fixation when performed) when the orthopedist uses an open method to treat the fracture.

New option: You may come across a physician treating medial malleolus fractures with closed manipulation and percutaneous fixation, but there is no CPT code for this procedure. -You would need to bill this method with an unlisted procedure code (27899, Unlisted procedure, leg or ankle),- Woodward says. Be sure to include the op note, a description of the procedure, and a letter describing a comparable established procedure.

You-ll note that CPT directs you to the 27808-27814 series in its index under both the -medial malleolus- and -lateral malleolus- listings. These codes actually represent bimalleolar fractures, which means the patient fractured both the lateral and medial malleoli. -Coders need to remember their physician should document fractures of two of the malleoli, which can include the posterior malleolus,- Woodward adds.

Closed: You should report 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) or 27810 (... with manipulation) if the orthopedist performs closed fracture care on a bimalleolar fracture.

Open: When the orthopedist uses an open surgical method to treat a bimalleolar fracture, report 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) with 824.4 (Fracture of ankle; bimalleolar, closed) or 824.5 (... bimalleolar, open) as the diagnosis.

Trap: If your physician sees a patient for a -bimalleolar equivalent fracture,- you may be tempted to report the bimalleolar fracture treatment codes for this injury. The AMA, however, advises you report either the lateral malleolus fracture treatment codes (27786-27792) or medial malleolus fracture treatment codes (27760-27766).

Trimalleolar fractures involve the same components as bimalleolar (medial and lateral) as well as the posterior lip of the tibia, which is termed the posterior malleolus for the purposes of this classification, although technically it is not a malleolus.

Closed: If the orthopedist performs a closed treatment, report 27816 (Closed treatment of trimalleolar ankle fracture; without manipulation) or 27818 (... with manipulation), with the diagnosis code 824.6 (Fracture of ankle; trimalleolar, closed) or 824.7 (... trimalleolar, open).

Open: 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 open trimalleolar treatments. -The posterior lip does not always require fixation; so that's why you would submit 27822,- Nelson says. -Otherwise, when the physician needs to address/fix the tibial posterior lip, you would report 27823.-

You already delved into codes covering treatment of medial malleolus fractures, but you should take into account the relatively new codes for posterior fractures CPT 2008 added.

Closed: When your orthopedist performs a closed method, you would report either 27767 (Closed treatment of posterior malleolus fracture; without manipulation) or 27768 (- with manipulation).

Open: For the open method, you should use 27769 (Open treatment of posterior malleolus fracture, includes internal fixation, when performed).

Many ankle fractures also involve disruption of the syndesmosis or distal tibiofibular joint. You can bill this in addition to the ankle fracture repair code using 27829 (Open treatment of distal tibiofibular joint [syndesmosis] disruption, includes internal fixation when performed), Woodward says. Diagnosis for this injury is 845.03 (Sprains and strains of tibiofibular [ligament], distal).

Benefit: If you-re in Alabama and reporting 27829 to Medicare, you could add $545.19 to your bottom line. If you-re in Manhattan, look for $695.74.

Don't miss: Also, always -read the op report to carefully determine the extent of fracture contamination and debridement,- Woodward says. Ask, how deep did the physician need to debride? You can still manage open fractures in a closed fashion, so -realistically, you still have the option of reporting 11010-11012 (Debridement - associated with open fracture[s] and/or dislocation[s] ...) codes with one of the closed management codes.- If you-re coding for extensive debridement in Alabama and submitting to Medicare, you could see a boost of $374.36. If you-re in Manhattan, the additional amount is $466.93.