How To Use CPT Code 27814

CPT 27814 refers to the open treatment of bimalleolar ankle fractures, which includes internal fixation when performed. This article will cover the description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information, similar codes, and examples of CPT 27814 procedures.

1. What is CPT 27814?

CPT 27814 is a medical code used to describe the open treatment of bimalleolar ankle fractures, which includes internal fixation when performed. This procedure involves surgically fixing two of the broken malleoli of the ankle, securing them with a plate and screws, wires, or pins. It is typically performed on unstable fractures that require additional support for proper healing.

2. 27814 CPT code description

The official description of CPT code 27814 is: “Open treatment of bimalleolar ankle fracture (eg, lateral and medial malleoli, or lateral and posterior malleoli, or medial and posterior malleoli), includes internal fixation, when performed.”

3. Procedure

The 27814 procedure involves the following steps:

  1. The patient is appropriately prepped and anesthetized.
  2. The provider makes an incision at the ankle joint.
  3. The fracture site is identified and explored.
  4. Fracture fragments are placed together in the correct anatomical position.
  5. The fragments are fixed with a plate and screws, wires, or pins.
  6. Hemostasis (stoppage of bleeding) is achieved.
  7. The wound is closed.
  8. A cast, brace, or splint is applied to aid in healing.
  9. Post-treatment X-rays may be taken to ensure correct alignment.

4. Qualifying circumstances

Patients eligible to receive CPT code 27814 services are those with bimalleolar ankle fractures, which involve two of the three malleoli (medial, lateral, or posterior). These fractures are typically unstable and require surgical intervention for proper healing. The patient’s medical history, physical examination, and imaging studies (such as X-rays) should support the need for this procedure.

5. When to use CPT code 27814

It is appropriate to bill the 27814 CPT code when a provider performs an open treatment of bimalleolar ankle fractures, including internal fixation when performed. This code should be used for patients with unstable fractures that require surgical intervention and fixation for proper healing and alignment.

6. Documentation requirements

To support a claim for CPT 27814, the following information should be documented:

  • Patient’s medical history and physical examination findings
  • Imaging studies (such as X-rays) confirming the bimalleolar ankle fracture
  • Operative report detailing the procedure, including the type of fixation used
  • Postoperative care plan, including the application of a cast, brace, or splint
  • Any complications or additional procedures performed during the surgery

7. Billing guidelines

When billing for CPT code 27814, it is essential to follow the appropriate guidelines and rules. Ensure that the patient’s medical records support the need for the procedure, and that all necessary documentation is included in the claim. Additionally, be aware of any specific payer requirements or policies related to billing for this code. Remember that external fixation codes should be used when external fixation is not part of the basic procedure.

8. Historical information

CPT 27814 was added to the Current Procedural Terminology system on January 1, 1990. The code was changed on January 1, 2008, with the previous descriptor being “Open treatment of bimalleolar ankle fracture, with or without internal or external fixation.”

9. Similar codes to CPT 27814

Five similar codes to CPT 27814 and how they differentiate are:

  • CPT 27822: This code is for open treatment of trimalleolar ankle fractures, which involve all three malleoli.
  • CPT 27823: This code is for open treatment of an ankle fracture with dislocation, which involves both fracture and dislocation components.
  • CPT 27826: This code is for open treatment of a posterior malleolar ankle fracture, which involves only the posterior malleolus.
  • CPT 27827: This code is for open treatment of an ankle dislocation without fracture, which does not involve any fractured malleoli.
  • CPT 27828: This code is for open treatment of an ankle fracture with syndesmotic disruption, which involves a more complex injury to the ankle joint.

10. Examples

Here are 10 detailed examples of CPT code 27814 procedures:

  1. A patient with a bimalleolar ankle fracture involving the medial and lateral malleoli, treated with open reduction and internal fixation using a plate and screws.
  2. A patient with a bimalleolar ankle fracture involving the medial and posterior malleoli, treated with open reduction and internal fixation using wires.
  3. A patient with a bimalleolar ankle fracture involving the lateral and posterior malleoli, treated with open reduction and internal fixation using pins.
  4. A patient with a bimalleolar ankle fracture and significant displacement, treated with open reduction and internal fixation using a combination of plates and screws.
  5. A patient with a bimalleolar ankle fracture and associated soft tissue injury, treated with open reduction, internal fixation, and wound debridement.
  6. A patient with a bimalleolar ankle fracture and associated ligament damage, treated with open reduction, internal fixation, and ligament repair.
  7. A patient with a bimalleolar ankle fracture and associated nerve injury, treated with open reduction, internal fixation, and nerve repair.
  8. A patient with a bimalleolar ankle fracture and associated vascular injury, treated with open reduction, internal fixation, and vascular repair.
  9. A patient with a bimalleolar ankle fracture and associated tendon injury, treated with open reduction, internal fixation, and tendon repair.
  10. A patient with a bimalleolar ankle fracture and associated compartment syndrome, treated with open reduction, internal fixation, and fasciotomy.

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