Part B Insider (Multispecialty) Coding Alert

Helpful hint: You will report 27828 most often

Don’t be fooled into thinking you can’t bill pilon fracture treatment with external fixation codes. Get your pilon fracture coding in check--and reimbursement on the way--with the clues below.

First step: Before you can select the appropriate code for a pilon fracture, you should know what type of injury these fractures describe. “A pilon, or tibial plafond fracture, is an intra-articular fracture of the distal tibia,” says Kenneth Swal, MD, an orthopedic surgeon in Dallas. “These injuries are usually caused by a trauma to the ankle that can also damage the soft tissues, so these fractures can be very difficult to treat.”

Three CPT Codes describe pilon fracture treatments:

• 27826--Open treatment of fracture of weight-bearing articular surface/portion of distal tibia (e.g., pilon or tibial plafond), with internal or external fixation; of fibula only

• 27827--... of tibia only

• 27828--... of both tibia and fibula.

Tricky: You might do a double take when reading the above code descriptors because two of the three codes mention fibula fixation, even though pilon fractures occur in the distal tibia. But don’t flip to a different section of CPT just yet.

Patients who have distal tibia fractures often require more than a tibia-only or fibula-only fixation, Swal says. In fact, Medicare data indicate that practices report code 27828 considerably more often than they report either 27826 or 27827, indicating that surgeons normally stabilize both the tibia and fibula at the same time. So you might wonder why you would ever use code 27826.

“Since these are complex injuries, the patient may receive temporary fixation on the day of injury, and receive permanent fixation at a later date,” says Paul K. Kosmatka, MD, orthopedic surgeon at the Marshfield Clinic. The delay allows the patient’s soft-tissue injuries to resolve, making it easier for the surgeon to address the tibial injury.

Example: The surgeon fixes the patient’s fibula on the day of the injury and places a temporary external fixator to stabilize the tibia. One to three weeks later, the patient returns to the OR, and the surgeon removes the external fixator and converts to internal fixation after the soft swelling has decreased.

Coding solution: The surgeon should report 27826 and 20690 on the first date of service, followed by 27827 on the second date of service.