How To Use CPT Code 27769

CPT 27769 describes the open treatment of a posterior malleolus fracture, including internal fixation, when performed. 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 27769?

CPT 27769 is used to describe the open treatment of a posterior malleolus fracture. This procedure involves making an incision over the fracture site of the posterior malleolus and placing the fracture fragments together in the correct anatomical position. Internal fixation, such as the use of screws and plates, may be performed to stabilize the fracture and prevent displacement while it heals. The purpose of this procedure is to keep the fracture aligned and relieve pain.

2. Official Description

The official description of CPT code 27769 is: ‘Open treatment of posterior malleolus fracture, includes internal fixation, when performed.’

3. Procedure

1. The provider begins by making an incision over the fracture site of the posterior malleolus.
2. They then explore the fracture site and identify the fracture fragments.
3. The provider carefully places the fracture fragments together in the correct anatomical position.
4. If necessary, they perform internal fixation using screws and plates to stabilize the fracture.
5. The provider thoroughly irrigates the wound with antibiotic solution and controls any bleeding.
6. They close the incision in layers and apply a splint to immobilize the injured joint.
7. Post-treatment, the provider may take X-rays to ensure the correct alignment of the fracture.

4. Qualifying circumstances

CPT 27769 is performed on patients with a posterior malleolus fracture that requires open treatment. The procedure is typically performed by a provider to keep the fracture in alignment, prevent displacement, and relieve pain. It may involve the use of internal fixation, such as screws and plates, to stabilize the fracture.

5. When to use CPT code 27769

CPT code 27769 should be used when the provider performs open treatment of a posterior malleolus fracture, including internal fixation, if necessary. It is important to note that this code should not be reported in conjunction with codes 27808-27823.

6. Documentation requirements

To support a claim for CPT 27769, the provider must document the following information:

• Diagnosis of a posterior malleolus fracture
• Details of the open treatment procedure, including the incision, exploration of the fracture site, placement of fracture fragments, and internal fixation if performed
• Date of the procedure
• Start and end time of the procedure
• Any additional procedures performed, such as wound irrigation or X-rays
• Signature of the provider performing the procedure

7. Billing guidelines

When billing for CPT 27769, ensure that the procedure meets the criteria for open treatment of a posterior malleolus fracture, including internal fixation if performed. It is important to note that CPT codes 27767-27769 should not be reported in conjunction with codes 27808-27823. Additionally, consider reporting any separately identifiable services, such as imaging or supplies, that are not included in the global period.

8. Historical information

CPT code 27769 was added to the Current Procedural Terminology system on January 1, 2008. There have been no updates to the code since its addition.

9. Examples

1. A provider performs open treatment of a posterior malleolus fracture in a patient who sustained a fall.
2. During the procedure, the provider uses internal fixation to stabilize the fracture fragments and keep them in alignment.
3. Another provider performs open treatment of a posterior malleolus fracture in a patient involved in a car accident.
4. The procedure involves making an incision, exploring the fracture site, and placing the fracture fragments together with screws and plates.
5. A third provider performs open treatment of a posterior malleolus fracture in a patient who twisted their ankle while playing sports.
6. The provider carefully aligns the fracture fragments and performs internal fixation to ensure stability.
7. A provider performs open treatment of a posterior malleolus fracture in a patient with osteoporosis.
8. The procedure involves placing the fracture fragments together and using screws and plates for internal fixation.
9. Another provider performs open treatment of a posterior malleolus fracture in a patient who fell down the stairs.
10. The provider ensures correct alignment of the fracture fragments and performs internal fixation to promote healing.