Orthopedic Coding Alert

Question: Can you please help us to report the following procedure?

DIAGNOSES: Fracture dislocation of right ankle with posterior and lateral malleolar fractures, deltoid ligament rupture, and encroachment on the ankle joint with lateral displacement of the talus.

OPERATIONS:

The operative note read as below:

"A longitudinal incision was then made on the lateral aspect of the ankle along the lateral aspect of the fibula extending approximately 10 cm proximally from the distal tip of the lateral malleolus. Going down to the subcutaneous layer, the bleeders were clamped. The fracture was clearly identified and appeared to be more of a Weber B type fracture. Attempted reduction of this was difficult and to some degree unsuccessful. Although the fracture line could be lined up, the distal and proximal portions were not on the same level with the distal portion being more laterally displaced. An X-ray at that point under fluoroscopy clearly showed that there was a gap on the medial side although in the lateral view, the joint was located.

A hockey-stick type incision was made on the medial side anteriorly in the medial gutter area and hockey sticking posteriorly about the distal end of the malleolus. This was taken down through subcutaneous tissue. An arthrotomy of the joint was performed and after some of the hematoma was removed from this area, the deltoid ligament was clearly noted to be invaginated into the joint. Using blunt dissection, this was removed from the joint and using Vicryl sutures was repaired to the distal aspect of the deltoid. The joint itself was noted to be scrapped in a serrated way. This was due to the previous dislocations that the patient had, as the talus had been posteriorly dislocated on the tibia.However at this point, there was little to be done about this and the joint talus could not be well located within the joint. Returning to the lateral side, we could now fully reduce the fibula with its 2 fragments readily aligned. A compression screw was then inserted perpendicular to the fracture line, as the reduction was held with a lion-jaw clamp. An 8-hole neutralization plate was then applied in the usual fashion with the 3 holes distal to the fracture line being fixed to the fibula with cancellous screws and cortical screws for which were used for the proximal end. This showed the joint to be very stable. A Cotton test was then performed with no instability noted in the syndesmosis and dorsiflexion and plantar flexion of the ankle as well as medial and lateral stressing of the os calcis in the subtalar joint area showed no instability in the joint itself."

Ohio Subscriber

Answer: Since your surgeon is working on the lateral and the posterior malleoli, you 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). According to CPT®, the fractures of the lateral and posterior malleoli constitute a bimalleolar fracture.

Your surgeon is also repairing the deltoid ligament, so you report code 27695 (Repair, primary, disrupted ligament, ankle; collateral). CPT® does not bundle the two codes, so you can report the two together.