Podiatry Coding & Billing Alert

Question: A new patient came into the office after rolling his left ankle by stepping off of a curb. After performing a level-four evaluation and management (E/M) service and a 2-view x-ray, the podiatrist diagnosed the patient with a displaced bimalleolar ankle fracture. The podiatrist repaired the ankle using closed treatment. Which CPT^® codes should I report for this case?

Montana Subscriber

Answer: You should submit the following codes on this claim:

• 27808 (Closed treatment of bimalleolar ankle fracture (eg, lateral and medial malleoli, or lateral and posterior malleoli or medial and posterior malleoli); without manipulation) for the ankle repair.
• 73600 (Radiologic examination, ankle; 2 views) for the x-ray.
• 99204 (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 moderate complexity …) for the evaluation and management (E/M) service. Note: Don’t forget to append modifier 57 (Decision for surgery) to 99204 to show that the ankle repair and the E/M were separate services.
• S82.842A (Displaced bimalleolar fracture of left lower leg, initial encounter for closed fracture) for the diagnosis code.

Bimalleolar fracture defined: A bimalleolar fracture involves a break in two bones of the malleolus — either the lateral and medial malleoli; the lateral and posterior malleoli; or the medial and posterior malleoli.