How To Use CPT Code 27816

CPT 27816 describes the closed treatment of a trimalleolar ankle fracture without manipulation. 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 27816?

CPT 27816 is used to describe the closed treatment of a trimalleolar ankle fracture without manipulation. This means that the provider fixes fractures of all three malleoli bones of the ankle (medial, lateral, and posterior) using a cast placement. The procedure is performed on stable fractures that do not require manipulation to realign the bones.

2. Official Description

The official description of CPT code 27816 is: ‘Closed treatment of trimalleolar ankle fracture; without manipulation.’

3. Procedure

1. When the patient is appropriately prepped and anesthetized, the provider treats all three fractured malleoli (medial, lateral, and posterior) with a cast placement.
2. The provider may perform an X-ray to examine the fracture before stabilizing it.
3. The provider advises the patient on ways to manage the pain.
4. The provider applies a cast, brace, or splint to stabilize the fracture.
5. Post-treatment X-rays may be taken to ensure the correct alignment of the bone.

4. Qualifying circumstances

CPT 27816 is used for stable fractures of all three malleoli (medial, lateral, and posterior) of the ankle that do not require manipulation. The procedure is performed when the patient has a trimalleolar ankle fracture and needs closed treatment without realignment of the bones.

5. When to use CPT code 27816

CPT code 27816 should be used when the provider performs closed treatment of a trimalleolar ankle fracture without manipulation. It is appropriate when the fracture is stable and does not require realignment of the bones. If the provider performs closed treatment with manipulation, a different code should be used.

6. Documentation requirements

To support a claim for CPT 27816, the provider must document the following information:

• Patient’s diagnosis of a trimalleolar ankle fracture
• Details of the closed treatment procedure performed
• Date of the procedure
• Start and end time of the procedure
• Any X-rays taken before and after the procedure
• Instructions given to the patient for managing pain
• Type of cast, brace, or splint applied
• Any post-treatment X-rays taken to ensure correct alignment

7. Billing guidelines

When billing for CPT 27816, ensure that the procedure performed is closed treatment of a trimalleolar ankle fracture without manipulation. It is important to accurately document the procedure and meet the necessary documentation requirements. Report CPT 27816 separately and do not report it with other codes unless appropriate and supported by the documentation.

8. Historical information

CPT 27816 was added to the Current Procedural Terminology system on January 1, 1990. There have been no updates to the code since its addition.

9. Examples

1. A patient sustains a trimalleolar ankle fracture and undergoes closed treatment without manipulation. The provider applies a cast to stabilize the fracture.
2. After a fall, a patient presents with a trimalleolar ankle fracture. The provider performs closed treatment without manipulation and applies a brace for stabilization.
3. A patient is diagnosed with a trimalleolar ankle fracture and undergoes closed treatment without manipulation. The provider applies a splint to stabilize the fracture.
4. Following a sports injury, a patient requires closed treatment of a trimalleolar ankle fracture without manipulation. The provider applies a cast to stabilize the fracture.
5. A patient presents with a trimalleolar ankle fracture and undergoes closed treatment without manipulation. The provider applies a cast and advises the patient on pain management techniques.
6. After a car accident, a patient sustains a trimalleolar ankle fracture and undergoes closed treatment without manipulation. The provider applies a brace for stabilization.
7. A patient fractures all three malleoli of the ankle and undergoes closed treatment without manipulation. The provider applies a splint to stabilize the fracture.
8. Following a fall, a patient is diagnosed with a trimalleolar ankle fracture and undergoes closed treatment without manipulation. The provider applies a cast and provides instructions for pain management.
9. A patient presents with a trimalleolar ankle fracture and undergoes closed treatment without manipulation. The provider applies a brace and advises the patient on ways to manage pain.
10. After a sports-related injury, a patient requires closed treatment of a trimalleolar ankle fracture without manipulation. The provider applies a splint and ensures correct alignment through post-treatment X-rays.