How To Use CPT Code 27766

CPT 27766 describes the open treatment of a fracture in the medial malleolus, which involves the use of internal fixation. This article will cover the description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples.

1. What is CPT Code 27766?

CPT 27766 is used to describe the open treatment of a fracture in the medial malleolus, specifically involving the use of internal fixation. This code is used when a healthcare provider performs a surgical procedure to treat a fracture in the inner surface of the ankle joint or the lower medial portion of the tibia. The procedure aims to keep the fracture in alignment, prevent displacement, and relieve pain.

2. Official Description

The official description of CPT code 27766 is: ‘Open treatment of medial malleolus fracture, includes internal fixation, when performed.’

3. Procedure

1. The healthcare provider prepares the patient for the procedure, ensuring appropriate anesthesia and prepping the surgical site.
2. An incision is made over the fracture site, carefully dissecting through the tissues until the bone is exposed.
3. The provider identifies and explores the fracture site, ensuring a clear view of the fracture fragments.
4. The fracture fragments are carefully aligned and placed in their correct anatomical position.
5. If necessary, the provider uses plates and screws to fix the fragments in place, providing stability and support for proper healing.
6. The surgical site is thoroughly irrigated with antibiotic solution to reduce the risk of infection.
7. Any bleeding is controlled, and the incision is closed in layers.
8. A splint is applied to immobilize the injured joint and promote healing.
9. Post-treatment, X-rays may be taken to confirm the correct alignment of the fracture.

4. Qualifying circumstances

CPT 27766 is performed on patients who have a fracture in the medial malleolus that requires open treatment with internal fixation. The procedure is typically performed by a healthcare provider who is experienced in orthopedic surgery. The use of internal fixation, such as plates and screws, is a key qualifying circumstance for this code.

5. When to use CPT code 27766

CPT code 27766 should be used when a healthcare provider performs open treatment of a fracture in the medial malleolus and utilizes internal fixation, such as plates and screws, to stabilize the fracture. This code should not be used for closed treatment of the fracture or when external fixation is used.

6. Documentation requirements

To support a claim for CPT 27766, the healthcare provider must document the following information:

• Diagnosis of the fracture in the medial malleolus
• Details of the procedure performed, including the use of internal fixation
• Date of the procedure
• Incision site and size
• Specific steps taken during the procedure, such as fracture reduction and fixation
• Any complications or additional procedures performed
• Post-treatment instructions and follow-up plans
• Signature of the healthcare provider performing the procedure

7. Billing guidelines

When billing for CPT 27766, ensure that the procedure meets the criteria for open treatment of a fracture in the medial malleolus with internal fixation. It is important to accurately document the use of internal fixation in the medical record. Additionally, be aware of any global periods or bundled services associated with this procedure.

8. Historical information

CPT 27766 was added to the Current Procedural Terminology system on January 1, 1990. The code underwent a change on January 1, 2008, with the addition of the phrase ‘with or without internal or external fixation’ to the official description.

9. Examples

1. A surgeon performs an open treatment of a fracture in the medial malleolus using internal fixation to stabilize the fracture.
2. An orthopedic specialist performs a surgical procedure to align and fixate a fracture in the inner surface of the ankle joint.
3. A healthcare provider performs open treatment of a fracture in the lower medial portion of the tibia, utilizing plates and screws for internal fixation.
4. A patient undergoes a surgical procedure to treat a fracture in the medial malleolus, with the use of internal fixation to ensure proper alignment and stability.
5. An orthopedic surgeon performs open treatment of a fracture in the medial malleolus, utilizing internal fixation to promote healing and prevent displacement.
6. A healthcare provider performs a surgical procedure to treat a fracture in the inner surface of the ankle joint, using plates and screws for internal fixation.
7. An orthopedic specialist performs open treatment of a fracture in the lower medial portion of the tibia, utilizing internal fixation to stabilize the fracture.
8. A patient undergoes a surgical procedure to align and fixate a fracture in the medial malleolus, ensuring proper healing and stability with internal fixation.
9. A surgeon performs open treatment of a fracture in the medial malleolus, utilizing plates and screws for internal fixation to maintain alignment and promote healing.
10. An orthopedic specialist performs a surgical procedure to treat a fracture in the inner surface of the ankle joint, using internal fixation to stabilize the fracture and prevent displacement.