Podiatry Coding & Billing Alert

Hint: A trimalleolar fracture involves 3 bones.

Fractures are one of the trickiest type of injuries to code because ICD-10-CM offers numerous different options depending upon specific information such as the location, type of fracture, the encounter, and how the fracture is healing. Ankle fractures are no exception, and if you don’t double-check the medical documentation for all of these details, you could be in danger of losing deserved revenue.

Ask yourself the following questions to make sure you always report clean ankle fracture claims in your podiatry practice.

Find Correct ICD-10-CM Code for Bimalleolar Fracture

Question 1: The patient has a displaced bimalleolar fracture of the right lower leg. This was a subsequent encounter for an open fracture type I with delayed healing. What is a bimalleolar fracture, and what ICD-10-CM code should I report on my claim?

Answer 1: In this case, you should report code S82.841H (Displaced bimalleolar fracture of right lower leg, subsequent encounter for open fracture type I or II with delayed healing) on your claim.

Bimalleolar ankle fracture defined: A bimalleolar ankle fracture involves two bones: the medial, distal, end of the tibia — or medial malleolus; and the distal, outside, end of the fibula — or lateral malleolus. Additionally, a bimalleolar fracture can also be a break of the medial and posterior malleoli or the lateral and posterior malleoli.

Identify Correct Option for Bimalleolar Fracture Treatment

Question 2: My podiatrist performed closed treatment of a lateral and medial malleoli ankle fracture without manipulation. Which CPT® code should I report for this procedure?

Answer 2: You should report 27808 (Closed treatment of bimalleolar ankle fracture (eg, lateral and medial malleoli, or lateral and posterior malleoli or medial and posterior malleoli); without manipulation) in this case. A lateral and medial malleoli ankle fracture is an example of a bimalleolar fracture.

Explore Lateral Malleolus Ankle Fracture ICD-10-CM Codes

Question 3: My podiatrist documented a displaced fracture of the lateral malleolus of the right fibula. This was an initial encounter for an open fracture type IIA. What ICD-10-CM code should I report for this injury?

Answer 3: You should report S82.61XC (Displaced fracture of lateral malleolus of right fibula, initial encounter for open fracture type IIIA, IIIB, or IIIC) on your claim.

Lateral malleolus ankle facture defined: When a patient has a lateral malleolus fracture, he has a fracture at the end of his fibula.

Differentiate Between Using Manipulation and not

Question 4: My podiatrist performed closed treatment of a lateral malleolus fracture without manipulation. He also applied a cast. Which CPT® code should I report on my claim?

Answer 4: You should report 27786 (Closed treatment of distal fibular fracture (lateral malleolus); without manipulation) in this case.

Don’t miss: If your podiatrist had performed closed treatment of a lateral malleolus fracture with manipulation, then you would report code 27788 (... with manipulation).

Patient Has Medial Malleolus Fracture? Turn to This ICD-10-CM Code Set

Question 5: According to the medical documentation, the patient has a nondisplaced fracture of the medial malleolus of the left tibia. This was an initial encounter for a closed fracture. What is a medial malleolus fracture, and what ICD-10-CM code should I report on my claim?

Answer 5: You should report S82.55XA (Nondisplaced fracture of medial malleolus of left tibia, initial encounter for closed fracture) on your claim.

Medial malleolus fracture defined: A medial malleolus fracture is a fracture of the inner side of the ankle at the end of the tibia.

Decode Surgical Medial Malleolus Options

Question 6: My podiatrist had to surgically visualize a medial malleolus fracture. This surgery required exposure to the environment. Which CPT® code should I report for this procedure?

Answer 6: For open treatment of a medial malleolus fracture, you should report 27766 (Open treatment of medial malleolus fracture, includes internal fixation, when performed), according to Arnold Beresh, DPM, CPC, CSFAC, in West Bloomfield, Michigan.

Remember, Trimalleolar Fracture Involves 3 Bones

Question 7: Per the medical documentation, the patient has a displaced trimalleolar fracture of the left lower leg. This was a subsequent encounter for an open fracture type I with delayed healing. What is a trimalleolar fracture, and which ICD-10-CM code should I report?

Answer 7: You should report S82.852H (Displaced trimalleolar fracture of left lower leg, subsequent encounter for open fracture type I or II with delayed healing).

Trimalleolar fracture defined: A trimalleolar fracture involves the medial malleolus and lateral malleolus and includes a posterior malleolus fracture, as well.

Figure Out How to Report Closed Trimalleolar Ankle Fracture Treatment

Question 8: My podiatrist performed closed treatment of a trimalleolar ankle fracture without manipulation. Which CPT® code should I report?

Answer 8: You should report code 27816 (Closed treatment of trimalleolar ankle fracture; without manipulation) for closed treatment of a trimalleolar ankle fracture without manipulation.