How To Use CPT Code 27822

CPT 27822 describes the open treatment of a trimalleolar ankle fracture, which involves the surgical fixation of the medial and lateral malleoli without fixation of the posterior lip. 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 27822?

CPT 27822 is used to describe the open treatment of a trimalleolar ankle fracture. This procedure involves surgically fixing the fractured medial and lateral malleoli of the ankle without fixation of the posterior lip. The purpose of this procedure is to provide additional support and stability to unstable fractures.

2. Official Description

The official description of CPT code 27822 is: ‘Open treatment of trimalleolar ankle fracture, includes internal fixation, when performed, medial and/or lateral malleolus; without fixation of posterior lip.’

3. Procedure

1. The provider begins by making an incision at the ankle joint after the patient is appropriately prepped and anesthetized.
2. They then identify and explore the fracture site to assess the extent of the injury.
3. The fractured fragments of the medial and lateral malleoli are carefully repositioned into their correct anatomical position.
4. The provider then uses plates, screws, wires, or pins to fixate the medial and lateral malleoli, ensuring stability and alignment.
5. After achieving hemostasis, the provider irrigates the surgical site and closes the incision.
6. A brace or cast may be applied to provide additional support during the healing process.
7. Post-treatment X-rays may be taken to confirm the correct alignment of the fractured malleoli.

4. Qualifying circumstances

CPT 27822 is performed on patients with trimalleolar ankle fractures that require surgical intervention for additional support and stability. The procedure involves fixing the fractured medial and lateral malleoli without fixation of the posterior lip. This code is used when the provider performs internal fixation using plates, screws, wires, or pins.

5. When to use CPT code 27822

CPT code 27822 should be used when the provider performs open treatment of a trimalleolar ankle fracture, fixing the medial and lateral malleoli without fixation of the posterior lip. This code should not be used if fixation of the posterior lip is performed. It is important to accurately document the procedure performed to ensure proper coding and billing.

6. Documentation requirements

To support a claim for CPT 27822, the provider must document the following information:

• Diagnosis of trimalleolar ankle fracture
• Description of the procedure performed, including the fixation method used
• Date of the procedure
• Start and end time of the procedure
• Any additional procedures performed during the same session
• Post-treatment X-rays, if applicable
• Signature of the provider

7. Billing guidelines

When billing for CPT 27822, ensure that the procedure meets the criteria for open treatment of a trimalleolar ankle fracture without fixation of the posterior lip. It is important to accurately document the procedure performed and any additional procedures performed during the same session. Modifier 62, Two surgeons, may be appended if the provider is acting as a cosurgeon with another provider. However, it is crucial to check with the payer regarding their specific guidelines for reporting cosurgeon modifiers.

8. Historical information

CPT 27822 was added to the Current Procedural Terminology system on January 1, 1990. The code underwent a code change on January 1, 2008, which expanded the description to include internal or external fixation and clarified the inclusion of the medial and/or lateral malleolus.

9. Examples

1. A patient sustains a trimalleolar ankle fracture and undergoes open treatment with internal fixation of the medial and lateral malleoli.
2. A provider performs open treatment of a trimalleolar ankle fracture without fixation of the posterior lip using plates and screws.
3. During surgery, a patient’s fractured medial and lateral malleoli are repositioned and fixed with wires and pins.
4. A trimalleolar ankle fracture is surgically treated by fixing the fractured medial and lateral malleoli with plates and screws.
5. A provider performs open treatment of a trimalleolar ankle fracture, fixing the medial and lateral malleoli without fixation of the posterior lip using wires and pins.
6. Using plates and screws, a provider surgically fixes the fractured medial and lateral malleoli of a trimalleolar ankle fracture.
7. A patient undergoes open treatment of a trimalleolar ankle fracture, with the provider fixing the medial and lateral malleoli using wires and pins.
8. During surgery, a provider performs open treatment of a trimalleolar ankle fracture without fixation of the posterior lip, fixing the fractured medial and lateral malleoli with plates and screws.
9. A trimalleolar ankle fracture is surgically treated by fixing the fractured medial and lateral malleoli with wires and pins.