Podiatry Coding & Billing Alert

Question: A patient visited our podiatry office with a swollen ankle and extreme pain. The podiatrist diagnosed a fracture. He performed a closed fracture care on her ankle and scheduled the patient for a open fracture care 3 days later. How should I code the encounter and the treatment?

Texas Subscriber

Answer: As the patient came to the office with the complaint, you should the visit with an appropriate E/M code based on the MDM points covered by your physician. You should select from the E/M codes 99201-99205 (Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components:…).

For the closed fracture repair, you should report 27786 (Closed treatment of distal fibular fracture (lateral malleolus); without manipulation). In the procedure, the podiatrist treats a lateral malleolus fracture, or a fracture of the distal end of the fibula by stabilizing the fracture and advising the patient on ways to manage the pain. He does not need to perform any reduction or adjustment to regain alignment. He then applies a cast, brace, or splint for a period of time to help with healing. He may also perform a separately reportable X-ray to examine the fracture.

For the subsequent closed fracture repair that your physician performed, you can report 27792 (Open treatment of distal fibular fracture (lateral malleolus), includes internal fixation, when performed). In this procedure, the physician treats a distal fracture of the fibula, or a break in the end of the fibula bone of the leg, including securing it with a plate and screws, wires, or pins. As the second procedure is in the global period of 90 days of the first procedure and it was planned, you should append modifier 58 (Staged or related procedure or service by the same physician or other qualified health care professional during the postoperative period) to 27792.