Podiatry Coding & Billing Alert

Question: How do we know which bimalleolar fracture code to report?

Colorado Subscriber

Answer: CPT^® directs you to the 27808-27814 series in its index under both the "medial malleolus" and "lateral malleolus" listings. These codes represent bimalleolar fractures, which usually means the patient fractured both the lateral and medial malleoli. This could also mean lateral and posterior malleolus, or medial and posterior malleolus, though those are much more rare. The podiatrist should document fractures of two of the malleoli, which can include the posterior malleolus.

Closed: If the podiatrist performs closed fracture care on a bimalleolar fracture, you should report 27808 (Closed treatment of bimalleolar ankle fracture [e.g., lateral and medial malleoli, or lateral and posterior malleoli or medial and posterior malleoli]; without manipulation) or 27810 (... with manipulation). You would look to S82.84-A (... bimalleolar fracture of ... lower leg, initial encounter for closed fracture) as the diagnosis.

Open: When the podiatrist uses an open surgical method to treat a bimalleolar fracture, report 27814 (Open treatment of bimalleolar ankle fracture, [e.g., lateral and medial malleoli, or lateral and posterior malleoli, or medial and posterior malleoli], includes internal fixation, when performed) with S82.84-B (... bimalleolar fracture of ... lower leg, initial encounter for open fracture type I or II) or S82.84-C (... bimalleolar fracture of ... lower leg, initial encounter for open fracture type IIIA, IIIB, or IIIC) as the diagnosis.

Caution: If your physician sees a patient for a "bimalleolar equivalent fracture," you may be tempted to report the bimalleolar fracture treatment codes for this injury. The AMA, however, advises you report either the lateral malleolus fracture treatment codes (27786-27792) or medial malleolus fracture treatment codes (27760-27766).

Note: A bimalleolar equivalent fracture is a fracture of either the medial or lateral malleolus with ligament disruption on the opposite side of the ankle - the most common being a lateral malleolus fracture with deltoid ligament disruption. This is usually a repair of the lateral malleolus with repair of the medial collateral ligament (deltoid) (27695, Repair, primary, disrupted ligament, ankle; collateral). This could also be repair/stabilization of the syndesmosis, which is 27829 (Open treatment of distal tibiofibular joint [syndesmosis] disruption, includes internal fixation, when performed).