Orthopedic Coding Alert

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Pilon fractures sometimes involve the fibula

If you think you can't bill external fixation codes along with pilon fracture treatment, you've fallen prey to one of the many myths surrounding pilon fracture coding. Follow our coding advice to put your pilon fracture coding on the right track.

Anatomical Terminology Is Key

First step: Before you can select the appropriate code for a pilon fracture, you should know what type of injury these fractures describe. A pilon" or tibial plafond fracture is an intra-articular fracture of the distal tibia " says Kenneth Swal MD an orthopedic surgeon in Dallas. "These injuries are usually caused by a trauma to the ankle that can also damage the soft tissues so these fractures can be very difficult to treat."

Three CPT codes describe pilon fracture treatments:
 

27826 - Open treatment of fracture of weight-bearing articular surface/portion of distal tibia (e.g. pilon or tibial plafond) with internal or external fixation; of fibula only

27827 - ... of tibia only

27828 - ... of both tibia and fibula.

Some coders might do a double take when reading the above code descriptors because two of the three codes mention fibula fixation even though pilon fractures occur in the distal tibia. But don't flip to a different section of CPT just yet.

Pilon Fractures Can Include the Fibula

Pilon fractures may or may not include an associated fibula fracture noncomitant to the injury says Paul K. Kosmatka MD orthopedic surgeon at the Marshfield Clinic. That's why these three codes are grouped the way they are - to address one particular injury complex and its various treatments. "The fibula fracture doesn't necessarily constitute a 'separate' injury but rather is part and parcel of the 'pilon' or 'plafond' fracture "

Kosmatka says.

Tip: "One selects the appropriate code based on which portions of the injury receive fixation not based on which bone is broken " Kosmatka says.

Therefore if the patient has tibia and fibula fractures but the physician only performs fixation on the tibia you should report 27827.

In such a case "the tibial fixation indirectly stabilizes the fibula " Kosmatka says. "Thus one could argue that the fibula has been 'fixed ' but not by any direct instrumentation. In this case I think it is not appropriate to code 27828." Instead you should simply report code 27827 only.

Report External Fixation Separately

Because your surgeon will probably repair the fracture with plates and screws don't forget to bill separately for the external fixation when warranted.

"In most cases physicians use a combination of plates and screws to realign and stabilize the distal tibia portion of the injury " Kosmatka says. "Depending on the fracture configuration one may also stabilize the distal fibula with a plate and screws or a rod/pin." But you shouldn't assume that the physician's work performing external fixation is included in the main procedure.

Because the descriptors refer to internal or external fixation you may be able to bill an additional code for your fixation services.

For instance if the physician performs internal and external tibia fixation you should include the internal fixation in your charge for 27827 but you can separately bill the external fixation with 20690 (Application of a uniplane [pins or wires in one plane] unilateral external fixation system).

27826 Is Correct for 2-Part Procedures

Patients who have distal tibia fractures often require more than a tibia-only or fibula-only fixation Swal says. In fact Medicare data indicate that practices report code 27828 considerably more often than they report either 27826 or 27827 indicating that surgeons normally stabilize both the tibia and fibula at the same time. So some coders might wonder why they would ever use code 27826.

"Since these are complex injuries the patient may receive temporary fixation on the day of injury and receive permanent fixation at a later date " Kosmatka says. The delay allows the patient's soft-tissue injuries to resolve making it easier for the surgeon to address the tibial injury.

Example: The surgeon fixes the patient's fibula on the day of the injury and places a temporary external fixator to stabilize the tibia. One to three weeks later the patient returns to the OR and the surgeon removes the external fixator and converts to internal fixation after the soft swelling has decreased.

Coding solution: The surgeon should report 27826 and 20690 on the first date of service followed by 27827 on the second date of service.
 
Don't forget: You should append modifier -58 (Staged or related procedure or service by the same physician during the postoperative period) to 27827 because the physician performed the initial fixation with the intent of returning to the OR to convert to internal fixation Kosmatka says.

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