Orthopedic Coding Alert

Do you know what a trimalleolar fracture involves?

Patients reporting to the orthopedist for treatment of ankle fractures can run the gamut from minor treatment to major surgery. Your job is to identify the treatment type and report the appropriate codes.

“Ankle fracture can be a simple break in one bone that you can still walk on or several fractures that may require surgery,” explained Karen F. Perry, CPC, CPC-I, OCS, during her HEALTHCON 2024 presentation “Current Orthopedic Coding Issues.”

And your surgeon could be repairing fractures in multiple ankle areas for the same patient at the same encounter, Perry explained. She has seen operative reports where a patient has fractured their ankle in three different places, but it’s pretty rare. Check out this advice on coding fracture care properly every time.

E/M, Imaging Mark Diagnostic Steps

When the surgeon suspects ankle fracture, they’ll begin with an evaluation and management (E/M) service. Then, they’ll also likely take an X-ray to identify the severity of the fracture and any bone displacement. You’ll code the evaluation and management (E/M) with the proper codes depending on encounter specifics; for the X-rays, you’ll be choosing from the following codes:

• 73600 (Radiologic examination, ankle; 2 views)
• 73610 (… complete, minimum of 3 views)
• 73615 (Radiologic examination, ankle, arthrography, radiological supervision and interpretation)

Once the surgeon locates the injured area, they might use a magnetic resonance imaging (MRI) or computed tomography (CT) scan for more information. This is particularly true if the fracture is complex or there might be soft tissue injuries accompanying the fracture.

Report any MRI or CT scans of the ankle with the following codes, depending on encounter specifics:

• 73700 (Computed tomography, lower extremity; without contrast material) through 73702 (… without contrast material, followed by contrast material(s) and further sections)
• 73721 (Magnetic resonance (eg, proton) imaging, any joint of lower extremity; without contrast material) through 73723 (… without contrast material(s), followed by contrast material(s) and further sequences)

Example: A patient that injured their right ankle after falling off an escalator reports to the orthopedist; it is the initial encounter to address this injury. After a physical and examination, the orthopedist orders a two-view ankle X-ray, which reveals a closed pilon fracture at the lower end of the left tibia. In order to better view the fracture, the orthopedist orders an MRI without contrast material.

• 73721 for the MRI
• 73600 for the X-ray
• Modifier RT (Right side) appended to 73721 and 73600 to indicate laterality
• The appropriate evaluation and management (E/M) code based on setting and encounter notes
• Modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) appended to the E/M code to show that the E/M service and the imaging services were significant and separately identifiable.
• S82.871A (Displaced pilon fracture of right tibia, initial encounter for closed fracture) appended to 73721, 73600, and the E/M code to indicate how the patient suffered the broken ankle
• W10.0XXA (Fall (on)(from) escalator, initial encounter) appended to 73721, 73600, and the E/M code to indicate how the patient suffered the broken ankle.

Know 5 Types of Ankle Fracture

Perry listed the five different types of ankle fracture, and their corresponding CPT® codes, to HEALTHCON attendees. She also paired up the surgical codes you’ll use for each fracture type. You’ll notice that some codes can represent surgeries for multiple types of ankle fractures:

Bimalleolar: This fracture involves any two of the ankle malleoli, (e.g., lateral and medial malleoli, lateral and posterior malleoli, or medial and posterior malleoli).

You’ll report surgery on bimalleolar fractures with the following codes:

• 27808 (Closed treatment of bimalleolar ankle fracture (eg, lateral and medial malleoli, or lateral and posterior malleoli or medial and posterior malleoli); without manipulation)
• 27810 (Closed treatment of bimalleolar ankle fracture (eg, lateral and medial malleoli, or lateral and posterior malleoli or medial and posterior malleoli); with manipulation)
• 27814 (Open treatment of bimalleolar ankle fracture (eg, lateral and medial malleoli, or lateral and posterior malleoli, or medial and posterior malleoli), includes internal fixation, when performed)

Lateral: This fracture occurs at the lower end of the fibula. You’ll report surgery on lateral fractures with the following codes:

• 27786 (Closed treatment of distal fibular fracture (lateral malleolus); without manipulation)
• 27788 (… with manipulation)
• 27792 (Open treatment of distal fibular fracture (lateral malleolus), includes internal fixation, when performed)
• 27808-27814

Medial: This fracture occurs on the articular surface of the ankle joint, explained Perry. You’ll report surgery on medial fractures with the following codes:

• 27760 (Closed treatment of medial malleolus fracture; without manipulation)
• 27762 (… with manipulation, with or without skin or skeletal traction)
• 27766 (Open treatment of medial malleolus fracture, includes internal fixation, when performed)
• 27808-27814

Posterior: This fracture occurs on the “lower back side of the shin bone,” said Perry. You’ll report surgery on posterior fractures with the following codes:

• 27767 (Closed treatment of posterior malleolus fracture; without manipulation)
• 27768 (… with manipulation)
• 27769 (Open treatment of posterior malleolus fracture, includes internal fixation, when performed)
• 27808-27814

Trimalleolar: This fracture occurs when the ankle breaks in three separate places. You’ll report surgery on trimalleolar fractures with the following codes:

• 27816 (Closed treatment of trimalleolar ankle fracture; without manipulation)
• 27818 (… with manipulation)
• 27822 (Open treatment of trimalleolar ankle fracture, includes internal fixation, when performed, medial and/or lateral malleolus; without fixation of posterior lip)
• 27823 (… with fixation of posterior lip).

Chris Boucher, MS, CPC, Senior Development Editor, AAPC