Podiatry Coding & Billing Alert

Hint: focus on treatment approach, and fixate on fixators.

Pilon fractures, or plafond fractures, involve trauma to the distal part of the tibia and the ankle joint and can potentially lead to long-term adverse effects. Such fractures are complicated, comminuted fractures that have a poor long-term outcome, explains Jordan Meyers, DPM, partner at Raleigh Foot and Ankle Center and consultant at Treace Medical Concepts, Inc. in Raleigh, North Carolina.

To correctly code pilon fracture treatments, you must know exactly which bones the podiatrist repaired, whether the treatment was open or closed, and if the podiatrist performed any external fixators. Follow these three documentation tips to keep your pilon fracture treatment claims clean.

Tip 1: Verify Open/Closed Treatment, Which Bones Were Repaired

Fractures are either open or closed. In open, or compound fractures, the bone punctures the skin, while closed fractures are contained within the skin. Likewise, treatments are either open (invasive surgery) or closed (non-invasive manipulation and/or traction). Proper code selection starts with selection of an open or closed treatment.

For closed treatments, you’ll report one of two codes: 27824 (Closed treatment of fracture of weight bearing articular portion of distal tibia (eg, pilon or tibial plafond); without manipulation) or 27825 (…with skeletal traction and/or requiring manipulation). The difference between the treatments, per the descriptors, lies in whether your podiatrist performed manipulation (involving a reduction, or adjustment, to regain alignment), which you would document with 27825. If the fracture does not require manipulation, you’ll report 27824.

For open treatments, you will report one of three codes, depending on which bones were repaired.

For the fibula, you’ll use 27826 (Open treatment of fracture of weight bearing articular surface/portion of distal tibia (eg, pilon or tibial plafond), with internal fixation, when performed; of fibula only)

• For the tibia, use 27827 (…of tibia only)
• For both, use 27828 (… of both tibia and fibula)

Remember: Pilon fractures sometimes include the fibula only, the tibia only, or both. Do not code the fractures separately. Instead, choose the code “based on which portions of the injury receive fixation, not on which bone is broken,” says Paul K. Kosmatka, MD, orthopedic surgeon at SMDC Medical Center, Duluth, Minnesota. “A fibula fracture doesn’t necessarily constitute a separate injury, but rather is part and parcel of the pilon or plafond fracture.”

Tip 2: Use These Codes for External Fixations

Podiatrists often use external fixators to apply traction on the fibula through talofibular ligaments as well. If the podiatrist uses pins or screws placed into the bone on both sides of the pilon fracture, they perform an open, or external, fixator procedure.

In such cases, you can report codes such as 20690 (Application of a uniplane (pins or wires in 1 plane), unilateral, external fixation system) or 20692 (Application of a multiplane (pins or wires in more than 1 plane), unilateral, external fixation system (eg, Ilizarov, Monticelli type)). The difference between the two codes lies in the number of rods the podiatrist places: if the provider places only one rod for the pins and wires, the fixation system is known as a uniplane system, and you would use 20690. For a system where the podiatrist places more than one rod on different planes — in other words, a multiplane system, also known as a ring fixation — you’ll use 20692.

Don’t forget: You can separately report 20690 in addition to 27825 when the surgeon uses an external fixator to realign the fracture.

Tip 3: Don’t Overlook This Modifier for Staged Fixations

Because pilon fractures can be complex injuries with extensive soft disuse damage and swelling related to trauma, many patients require a temporary fixation in the short term with a more complex follow-up fixation occurring later. This allows the swelling to resolve without frequent splint changes, which can hinder this healing of the soft tissue. So, the podiatrist may stabilize the tibia temporarily using an external fixator, then place an internal fixator after the soft tissue swelling resolves.

For example: The podiatrist fixes the patient’s fibula on the day of the injury and places a temporary external fixator to stabilize the tibia. No incision is made through the damaged tissue. Two weeks later, the patient returns to the operating room (OR), where the podiatrist removes the external fixator and converts to internal fixation now the soft swelling has reduced. This second procedure was planned ahead of time.

In this series of encounters, since the surgeon plans the second step of this two-step procedure in advance, you should report 27826 and 20690 on the first date of service followed by 27828 on the second date of service. For 27828, you’ll append modifier 58 (Staged or related procedure or service by the same physician during the postoperative period) because the podiatrist performed the initial external fixation with the intent of performing the second procedure to convert it to an internal fixation.