Podiatry Coding & Billing Alert

Question: A new patient came into the podiatrist’s office with a badly injured right ankle that he sustained in a mountain bike accident. The patient hit a tree and fell off his bike, hurting his ankle. After a comprehensive history and examination, the podiatrist diagnosed a displaced, right, closed bimalleolar ankle fracture. According to the podiatrist’s notes, he performed high-level medical decision making (MDM). The podiatrist stabilized the injury using open treatment and internal fixation. How should I code this encounter?

Montana Subscriber

Answer: For your CPT^® codes, you should report the following:

• 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. Note: Don’t forget to append modifier RT (Right side) 27814 to indicate laterality, if your 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 evaluation and management (E/M) visit. Don’t forget to append modifier 57 (Decision for surgery) to 99205 to show that the E/M led to the podiatrist deciding to operate.

Diagnosis coding: For the ICD-10 code, you should report S82.841A (Displaced bimalleolar fracture of right lower leg, initial encounter for closed fracture).