Orthopedic Coding Alert

Question: The orthopedic surgeon performs a closed reduction and percutaneous pinning for a patient with a left ankle fracture with syndesmotic injury. During the procedure, the surgeon makes a small stab incision over the medial malleolus and lateral malleolus. Then using a large reduction clamp, the surgeon reduces the synostosis. Then, she places a pair of 3.5 mm fully threaded cortical screws through the fibula into the tibia, getting all four cortices and holding the syndesmosis in place. The surgeon then removed the reduction clamp. Since there was no significant bleeding, the surgeon placed a nylon suture to close the incisions, injected 10 CCs of 0.25% Marcaine into the incision site and placed a sterile, soft dressing. What is the correct coding for this scenario?

Tennessee Subscriber

Answer: As involved as this scenario is, you'll only need a single CPT^® code to represent all your surgeon's work. on the claim, report 27842 (Closed treatment of ankle dislocation; requiring anesthesia, with or without percutaneous skeletal fixation) for the ankle repair.

All of the services you describe in your scenario - anesthesia, skeletal fixation, etc. - are included in the surgical package for 27842.