Orthopedic Coding Alert

Question: Our surgeon documented a diagnosis of left ankle Weber C fracture in lateral malleolus and syndesmotic disruption. The following procedures were done to correct these conditions:

1.   Open reduction and internal fixation, left ankle lateral malleolus fracture.

2.   Open reduction and internal fixation, left ankle syndesmosis disruption.

Please suggest appropriate codes for the procedures.

Alabama Subscriber

Answer: For the open reduction and internal fixation of the left ankle lateral malleolus fracture, you report code 27792 (Open treatment of distal fibular fracture [lateral malleolus], includes internal fixation, when performed). You will need to check if the fracture was an open or closed fracture. Accordingly, you may report diagnosis codes 824.2 (Fracture of lateral malleolus closed) or 824.3 (Fracture of lateral malleolus open).

For the open repair of the disrupted left ankle syndesmosis, you report 27829 (Open treatment of distal tibiofibular joint [syndesmosis] disruption, includes internal fixation, when performed). This code is inclusive of internal fixation. For the acute disruption of the syndesmosis, you report 845.03 (Tibiofibular [ligament] sprain distal).

Caveat: Remember to check documentation for the approach your surgeon used. You can report code 27829 in addition to 27792 when the syndesmosis repair requires a separate incision.