Orthopedic Coding Alert

Hint: Bones and fixators guide you to the correct codes.

When your surgeon treats patients with complex, traumatic bone injuries, you may have documentation indicating a pilon fracture -- which may throw you into unchartered waters. But if you're paying attention to which bones were repaired, whether the repairs were internal or external, and any staged fixations, you'll be well on your way to accurately coding pilon cases.

Grasp These Pilon Basics: Pilon fractures are intra-articular fractures in the dome of the distal tibial articular surface. These extend into the adjacent metaphysis. Trauma to the ankle is the usual cause for these fractures. "The term 'pilon' refers to the mechanism of injury when one bone is driven into another bone with force," says 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. The fibula may or may not be involved in pilon fractures. "The fibula is not always fractured," says Stout.

Take note: The fibular fracture is an integral part of the pilon fracture when present. It is not a separate fracture.

Discern Open or Closed Treatment

You will need to choose from the following three codes when reporting an open treatment for a pilon fracture:

• 27826 (Open treatment of fracture of weight bearing articular surface/portion of distal tibia [eg, pilon or tibial plafond], with internal fixation, when performed; of fibula only)

• 27827 (Open treatment of fracture of weight bearing articular surface/portion of distal tibia [eg, pilon or tibial plafond], with internal fixation, when performed; of tibia only)

• 27828 (Open treatment of fracture of weight bearing articular surface/portion of distal tibia [eg, pilon or tibial plafond], with internal fixation, when performed; of both tibia and fibula)

When reporting a closed treatment for a pilon fracture, you should use code 27825 (Closed treatment of fracture of weight bearing articular portion of distal tibia [eg, pilon or tibial plafond], with or without anesthesia; with skeletal traction and/or requiring manipulation).

Look For Bones Repaired

The codes 27826, 27827, and 27828 specify the bone involved in the descriptor. You report 27826 if the internal fixation involves only the fibula, 27827 when it involves only the tibia, and 27828 when it involves both the tibia and the fibula. Remember, the codes are based on which bone was repaired," says Bill Mallon, MD, medical director, Triangle Orthopedic Associates, Durham, N.C. "You do not select a code depending upon which bone was involved," stresses Stout.

Example: If you read that both the tibia and fibula were fractured, but the surgeon performed the fixation on the tibia only, you should report 27827 and not 27828. This is because the fixation of the tibia itself stabilizes the fibular fracture. The fibula does not need instrumentation individually.

Scan the Note for External Fixation

Your surgeon may use pins, screws, or wires to stabilize and align the reconstructed distal articular block to the metaphysis. The external fixator may span the ankle joint and incorporate the foot though it may limit ankle movements. "External fixators are particularly used when the injury is an open fracture or there is extensive fracture blistering present," says Stout.

Alternatively, your surgeon may use an external fixator to incorporate and distract the talus. By doing so, the surgeon is indirectly trying to restore the fibular length by applying traction on the fibula through the intact talofibular ligaments. "External fixators are used for restoring length and maintaining alignment of the fracture until it can start to heal," says Mallon. External stabilizers are used "because very complex comminuted fractures can often not be improved with internal fixation," says Mallon.

"External fixators are most commonly used as a temporizing measure until the soft tissues have healed enough to permit use of internal hardware. The fixator is assembled and then the fracture is distracted (closed reduction) to restore length and realign the fracture fragments," adds Stout.

Example: You can separately report code 20690 (Application of a uniplane [pins or wires in oneplane], unilateral, external fixation system) in addition to 27825 when the surgeon uses an external fixator to realign the fracture. You may report 20692 (Application of a multiplane [pins or wires in more than 1 plane], unilateral, external fixation system [eg, Ilizarov, Monticelli type]) if the surgeon uses a multiplane fixation system.

Coding caveat: Don't assume that the external fixator is integral to the main procedure when selecting your codes. The code descriptors, 27826, 27827, 27828, 20690, and 20692 distinctly mention internal and external fixation. Your surgeon may internally fix one bone and use an external fixator for the other. So you should always report and collect payment for an external fixator.

Don't Overlook Staged Fixations

The pilon fracture can involve complex injuries and several fragments. Since trauma is the commonest cause, there can be extensive soft disuse damage and swelling accompanying the fracture.

In this situation, the surgeon may plan a temporary fixation on the day of the injury, followed by a more definitive fixation at a later date. "Many surgeons avoid performing internal fixation after initial external fixation due to reasons like contamination of the wounds from the pin sites," says Mallon.

Example: When your surgeon initially uses an external fixator for the tibia and an internal fixator to stabilize the fibular fracture, you report code 27826 and 20690. You may then read that after around two weeks, the patient returned to the OR and the surgeon removed the external fixator and did an internal fixation. You then report 27827.

Do not forget to append modifier -58 (Staged or related procedure or service by the same physician during the postoperative period) to 27827. Your surgeon did intend to return the patient to the OR for an internal fixation after the initial external fixation.