Orthopedic Coding Alert

Question: I just started coding for an orthopedic practice in a mountainous area, and we get our share of vacationing patients with injuries. This one is my first, and I want to get it just right. Notes indicate that a patient reported to the orthopedist with a badly injured right ankle sustained in a mountain bike accident; he hit a tree and fell off his bike, hurting the ankle. After a comprehensive history and examination, the surgeon diagnosed a closed right bimalleolar ankle fracture. Notes indicate high-level medical decision making (MDM). She stabilized the injury using open treatment and internal fixation, with instructions for one of his hometown orthopedists to handle the patient’s aftercare. How should I code this encounter?

Utah Subscriber

Answer: You’ll need a lot of help from modifiers in this case, so buckle up and here we go!

CPT^® coding: Report the following codes and modifiers for this claim:

• 27814 (Open treatment of bimalleolar ankle fracture (eg, lateral and medial malleoli, or lateral and posterior malleoli, or medial and posterior malleoli), includes internal fixation, when performed) for the ankle fracture fix.
• Modifier 54 (Surgical care only) appended to 27814 to show that you are only coding for your orthopedist’s portion of the surgical package.
• Modifier RT (Right side) appended to 27814 to indicate laterality, if the payer requires it.
• 99205 (Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; Medical decision making of high complexity …) for the E/M.
• Modifier 57 (Decision for surgery) appended to 99205 to show that the E/M led to the surgeon deciding to operate.

ICD-10 coding: You’ll choose from ICD-10 codes S82.841A (Displaced bimalleolar fracture of right lower leg, initial encounter for closed fracture) and S82.844A (Nondisplaced bimalleolar fracture of right lower leg, initial encounter for closed fracture) to represent the patient’s injury, depending on encounter specifics. Attach the proper fracture diagnosis code to 27814 and 99205.

You might also consider including an external cause ICD-10 code to paint a more complete picture of the patient’s injury. For this patient’s accident, take a look at V17.0--A (Pedal cycle rider injured in collision with fixed or stationary object; initial encounter).