Wiki EXCISION OF AVULSION FRACTURE, LEFT LATERAL MALLEOLUS WITH REPAIR OF THE LATERAL LIGAMENTS

[Jwindsor17]

Unsure how to proceed with the coding of this case. I have looked at 27695, 27792, 27826 & 28193 but unsure as none of these seem to truly fit to me.


POSTOPERATIVE DIAGNOSIS: UNUNITED AVULSION FRACTURE, LEFT LATERAL MALLEOLUS

PROCEDURE: EXCISION OF AVULSION FRACTURE, LEFT LATERAL MALLEOLUS WITH REPAIR OF THE LATERAL LIGAMENTS

ANESTHESIA: GENERAL

DESCRIPTION OF PROCEDURE: Under adequate general anesthesia, the left lower extremity was prepped and draped in the usual sterile fashion. The extremity was exsanguinated with an Esmarch, and tourniquet was inflated. An incision was made over the lateral malleolus distally. The ligaments were split in line with the incision, and there was an unstable fracture fragment of the tip of the lateral malleolus that was about a cm in diameter. The fragment was sharply excised. The lateral ligaments were then repaired using an Arthrex 3.0 Knotless SutureTak anchor with a #2 FiberWire suture attached. The suture was placed in Bunnell fashion and then the knotless mechanism was activated, securing the fixation of ligaments to the exposed tip of the lateral malleolus. The wound was irrigated and closed with 2-0 Vicryl and 3-0 nylon. A sterile dressing and short leg splint were applied. The patient was taken to recovery room, awake and in stable condition.

 

[MI_CODER]

I would code this as 27641-LT. The lateral malleolus is the distal end of the fibula and the documentation states that the fracture fragment was excised from the tip of the lateral malleolus. I don't believe you could code for 27695 because the documentation makes it sound like they had to cut the lateral ligaments in order to gain access to the fragment. If they have to cut the ligaments then they have to repair them as well. The only way you could code for the ligament repair is if they were already torn or diseased.

 

[Jwindsor17]

I would code this as 27641-LT. The lateral malleolus is the distal end of the fibula and the documentation states that the fracture fragment was excised from the tip of the lateral malleolus. I don't believe you could code for 27695 because the documentation makes it sound like they had to cut the lateral ligaments in order to gain access to the fragment. If they have to cut the ligaments then they have to repair them as well. The only way you could code for the ligament repair is if they were already torn or diseased.

The program I use is ASCExpert & the lay description for CPT 27641 states:

The physician performs a partial excision of the tibia in 27640 or the fibula in 27641 to remove infected bone. An incision is made over the affected part of the bone and the underlying soft tissues are divided to expose it. The periosteum is reflected and the infected portion of bone is removed and irrigated. The excavation of bone may excise a crater-like piece, leave a small saucer-like shelf depression in the bone, or may remove a portion of the shaft (diaphysis) of a long bone. If a significant portion of bone is removed, the physician may use bone graft material to fill the cavity left in the bone. The periosteum is closed over the bone, the soft tissues are sutured closed, and a soft dressing is applied.

The operative report does not states any infection to the bone. Do you still feel this code is correct?

 

[MI_CODER]

The program I use is ASCExpert & the lay description for CPT 27641 states:

The physician performs a partial excision of the tibia in 27640 or the fibula in 27641 to remove infected bone. An incision is made over the affected part of the bone and the underlying soft tissues are divided to expose it. The periosteum is reflected and the infected portion of bone is removed and irrigated. The excavation of bone may excise a crater-like piece, leave a small saucer-like shelf depression in the bone, or may remove a portion of the shaft (diaphysis) of a long bone. If a significant portion of bone is removed, the physician may use bone graft material to fill the cavity left in the bone. The periosteum is closed over the bone, the soft tissues are sutured closed, and a soft dressing is applied.

The operative report does not states any infection to the bone. Do you still feel this code is correct?

I would still use 27641. While I agree that the CPT lay description states "infected" bone, the CPT code itself doesn't specify the reasoning for the partial excision. All it states is partial excision of the fibula and that's exactly what your provider is doing. I've always been taught to look at the CPT lay description as a guide. It's an excellent resource and I use it all the time but you have to remember that many times they're just giving a few examples of how that procedure might be performed. I believe that as long as the CPT code itself doesn't specifically state that the code is only to be used for an infected bone then you're good.

I'd like to add that there's a CPT Assistant Q&A where someone asked how an excision of a metatarsal nonunion fracture fragment should be coded. They answered by saying the correct coding would be 28122. While I know your situation is different, I believe it still falls along the same lines. A fracture fragment is being excised and they're saying the correct code to use would be a partial excision of that specific body part.

Bone fracture fragment excision at base of fifth metatarsal
CPT Assistant, August 2020 Page: 14 Category: Frequently Asked Questions

Question:

How should treatment of a nonunion avulsion fracture at the base of the left fifth metatarsal be reported when the surgery consists of excising the bone fracture fragment?

Answer:

This procedure is reported with CPT code 28122, Partial excision (craterization, saucerization, sequestrectomy, or diaphysectomy) bone (eg, osteomyelitis or bossing); tarsal or metatarsal bone, except talus or calcaneus. It would not be appropriate to report a fracture repair code when excising a nonunion fragment. It also would not be appropriate to report a repair of nonunion/malunion code when only excising a fragment. Code 28122 describes partial excision of a metatarsal bone and a portion of the metatarsal bone was excised in this scenario. Therefore, code 28122 is the appropriate code to report.