Wiki Closed reduction with incision

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suec

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Hi, Has anyone come across a tibial fracture and the planned procedure was a closed reduction being performed in the OR. The fracture couldn’t be reduced so a small incision was made and a lever was inserted to lift the tibia into alignment. The lever was removed and the leg casted. No internal fixation was done. We are discussing if this would’ve coded as a closed reduction, CPT 27752 even though an incision was made for the lever. Use the unlisted CPT 27899. Or code as ORIF CPT 27758 because an incision was made. (maybe with modifier 52). Any thoughts or suggests. Thank you.
 
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I would probably use 27752 since it says with or without skeletal traction which is kind of what you are describing. I assume it was a pokehole or very small percutaneous incision?
 
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If an incision is made to reduce the fragments directly, that is, by definition an open reduction. Internal fixation not required for coding.
Skeletal traction is different, and is applied distant from the fracture site. Not at all the same thing.
You do not need a 52 modifier.
 
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The incision was made to insert the lever which was used to realign the fracture. The fracture was not viewed directly but thru imaging. The fracture was not directly viewed and questioning if it would be considered open just because a small incision was made for lever.
 
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CPT Definition of Open Treatment:

Open treatment: The site is opened surgically to expose
the fracture/dislocation to the external environment for
treatment, or the fracture/dislocation is treated through
the traumatic wound or an extension thereof or is treated
with an intramedullary nail or other internal fixation
device placed through a surgical exposure that is remote
from the fracture site with or without direct visualization
of the fracture site.

As noted above, you do not need to visualize the fracture. This is very clearly open treatment. These definitions were revised in 2022
 
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I agree that is the definition in the CPT book, I don't think we are debating closed/percutaneous/open definitions. However, if the question is whether 27758 can be used, that code specifically states: Open treatment of tibial shaft fracture (with or without fibular fracture), WITH PLATE/SCREWS, with or without cerclage. So, according to this specific code, internal fixation IS required for coding.
Even if there was no direct visualization, there were no plates or screws in this example. Maybe 27758-52 would be best unless CPT Asst. directs differently.
It would help to see the whole op note redacted to make sure we are even talking about the correct codes and what exactly was done.
There are CPT Assistant articles for codes 27750, 27752, 27756, and 27758, have you checked there?

In contrast to 27758 where it specifically includes "with plate/screws", see some of the other codes where it states "includes internal fixation when performed" (e.g.; 27766, 27769, 27784, 27792, 27827). That is the difference. AT least to my eye and reading.
 
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Amy - you're entirely correct - I had forgotten about the IMN vs plate differentiator and was focused on definition of open reduction.
BTW - the CPT-A article gives no guidance here.

I would code this as 27758-52, as it is open treatment technically, but no internal fixation was applied.
 
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Thank You all for the input. Appreciate you taking the time to help. Here is the op report.
Dx: Right closed displaced mid shaft tibia fracture.
A time out call, laterality & procedure confirmed. Patient relaxed & under anesthesia. All necessary equipment was available & appropriate radiographs were on display. I made 2-3 attempts to perform a closed reduction. Unfortunately, I was unable to adequately reduce the fracture in the sagittal plane. Thus I made a small stab incision anteriorly. I bluntly dissected down to the tibial crest. I was able to reduce a percutaneous instrument to lever the fracture into much improved alignment nearly an atomic on lateral view with over 50% apposition on the AP. Thus i irrigated this incision and closed it with 1 absorbable suture. A sterile dressing was applied. I then placed the patient in a well-padded long leg cast. Final AP & lateral views demonstrated maintained length line rotation of the fracture.
 
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nraizman@gmail.com said:
Agree with 27758-52 as well, though this op report is weak sauce.
Surgeons need better education on how to dictate operative reports. I try.
Click to expand...
Dr. Raizman, thank you for trying! :) It is really helpful to have providers participate here with us as well for education.
Physician advocates were always my best help when it came to coding, billing and documentation when I worked in practice management. If I could not make progress or any meaningful change with a provider's documentation behaviors I would enlist physician partners to help. That sometimes worked. Showing them the money worked too. Especially if the provider is paid by RVUs and not salary. It directly impacts their production and claim payment lag times. Not to mention, the number of appeals and corrections as well as difficulty in obtaining prior auth if their office and other encounters are documented poorly too.
Agree, if that is all there was to the op note, it is not great.
 
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