How To Use CPT Code 27823

CPT 27823 describes the open treatment of a trimalleolar ankle fracture, which involves the fixation of the medial and/or lateral malleolus, as well as 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 27823?

CPT 27823 is used to describe the open treatment of a trimalleolar ankle fracture. This procedure involves surgically fixing all three fractured malleoli of the ankle, including the medial, lateral, and posterior malleoli. The provider uses plates, screws, wires, or pins to secure the malleoli at the medial and lateral sides, and also applies fixation to the posterior malleolus. This procedure is typically performed on unstable fractures that require additional support.

2. Official Description

The official description of CPT code 27823 is: ‘Open treatment of trimalleolar ankle fracture, includes internal fixation, when performed, medial and/or lateral malleolus; with 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 provider carefully aligns the fracture fragments in their correct anatomical position.
4. Using plates, screws, wires, or pins, the provider fixes the medial and lateral malleoli to provide stability.
5. Fixation is also applied to the posterior malleolus to ensure proper healing.
6. After achieving hemostasis, the provider closes the incision and may apply a cast for additional support.
7. Post-treatment X-rays may be taken to confirm the correct alignment of the fractured bones.

4. Qualifying circumstances

CPT 27823 is performed on patients with trimalleolar ankle fractures, which involve fractures of the medial, lateral, and posterior malleoli. The procedure is typically reserved for unstable fractures that require additional support. The provider must perform internal fixation, using plates, screws, wires, or pins, to secure the fractured bones. It is important to note that the procedure is only reported when fixation of the posterior lip is performed.

5. When to use CPT code 27823

CPT code 27823 should be used when the provider performs open treatment of a trimalleolar ankle fracture and includes internal fixation of the medial and/or lateral malleolus, as well as fixation of the posterior lip. It is important to ensure that all qualifying circumstances are met before reporting this code.

6. Documentation requirements

To support a claim for CPT 27823, the provider must document the following information:

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

7. Billing guidelines

When billing for CPT 27823, ensure that the procedure meets all the qualifying circumstances and that the fixation of the posterior lip is performed. It is important to follow the specific guidelines provided by the payer regarding documentation and any additional requirements for reporting this code. Modifier 62, Two surgeons, may be appended if the provider is acting as a cosurgeon with another provider.

8. Historical information

CPT 27823 was added to the Current Procedural Terminology system on January 1, 1990. The code underwent a change on January 1, 2008, which expanded the description to include fixation of the posterior lip.

9. Examples

1. A patient sustains a trimalleolar ankle fracture due to a fall. The provider performs open treatment of the fracture, fixing the medial and lateral malleoli, as well as the posterior lip.
2. During a sports-related injury, a patient fractures their ankle, resulting in a trimalleolar fracture. The provider performs open treatment of the fracture, securing the fractured bones with plates and screws.
3. A patient involved in a car accident suffers a trimalleolar ankle fracture. The provider performs open treatment of the fracture, using wires and pins to fix the fractured bones.
4. After a fall from a height, a patient presents with a trimalleolar ankle fracture. The provider performs open treatment of the fracture, applying fixation to the medial and lateral malleoli, as well as the posterior lip.