Orthopedic Coding Alert

Question: Can you please help us to report the following procedure that our surgeon did:

Diagnosis: Comminuted fracture, right distal femur.

Operative procedure:  Closed reduction with retrograde intramedullary nailing of distal femur fracture.

The operative note reads as follows:

"An incision was made midline, and the patellar tendon split.  This allowed us to drill a hole with a Steinman pin and match an appropriate angle and location is verified by image intensification in both planes.  This allowed us to over ream the appropriate level and we selected a retrograde nail.  We inserted a distal fragment across the fracture site without great difficulty and impacted in distally at the appropriate level. This allowed us to use the guides to make a separate stab incision laterally and we were able to place a Steinmann pin in the distal femoral condyle."

North Carolina Subscriber

Answer: You report a simple intramedullary nail for femur fracture. Look at code 27509 (Percutaneous skeletal fixation of femoral fracture, distal end, medial or lateral condyle, or supracondylar or transcondylar, with or without intercondylar extension, or distal femoral epiphyseal separation).