How To Use CPT Code 27828

CPT 27828 describes the open treatment of a fracture of the weight bearing articular surface or portion of the distal tibia, with internal fixation, when performed on both the tibia and fibula. 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 27828?

CPT 27828 can be used to describe the open treatment of a fracture in the weight bearing articular surface or portion of the distal tibia. This procedure involves surgically fixing the fracture by securing both the tibia and fibula with plates and screws, wires, or pins.

2. Official Description

The official description of CPT code 27828 is: ‘Open treatment of fracture of weight bearing articular surface/portion of distal tibia (eg, pilon or tibial plafond), with internal fixation, when performed; of both tibia and fibula.’

3. Procedure

1. The provider prepares the patient and administers anesthesia.
2. An incision is made at the ankle joint to access the fracture site.
3. The provider identifies and explores the fracture site.
4. The fractured fragments of the distal tibia are carefully repositioned in their correct anatomical position.
5. The provider applies fixation using plates, screws, wires, or pins to both the tibia and fibula to help retain the fractured fragments in their correct anatomical position.
6. The site is irrigated to clean it and achieve hemostasis.
7. The incision is closed, and a cast or brace may be applied to stabilize the fracture.
8. Post-treatment X-rays may be taken to ensure correct alignment.

4. Qualifying circumstances

CPT 27828 is performed on patients with a fracture in the weight bearing articular surface or portion of the distal tibia. The procedure requires internal fixation using plates, screws, wires, or pins on both the tibia and fibula.

5. When to use CPT code 27828

CPT code 27828 should be used when the provider performs open treatment of a fracture in the weight bearing articular surface or portion of the distal tibia, with internal fixation, on both the tibia and fibula. It is important to ensure that the procedure meets the specific criteria outlined in the code description.

6. Documentation requirements

To support a claim for CPT 27828, the provider must document the following information:

• Patient’s diagnosis and the need for open treatment of the fracture
• Details of the procedure performed, including the use of internal fixation on both the tibia and fibula
• Date of the procedure
• Any additional procedures or treatments performed
• Post-treatment X-rays, if taken
• Signature of the provider

7. Billing guidelines

When billing for CPT 27828, ensure that the procedure meets the specific criteria outlined in the code description. It is important to accurately report the use of internal fixation on both the tibia and fibula. Review the payer’s guidelines for any additional requirements or modifiers that may be necessary for proper reimbursement.

8. Historical information

CPT 27828 was added to the Current Procedural Terminology system on January 1, 1993. There have been historical changes to the code, including a code change on January 1, 2008, which expanded the description to include internal or external fixation.

9. Examples

1. A patient sustains a fracture in the weight bearing articular surface of the distal tibia and fibula. The provider performs open treatment of the fracture, securing both the tibia and fibula with plates and screws.
2. A patient presents with a pilon fracture of the distal tibia and fibula. The provider performs open treatment of the fracture, using internal fixation on both the tibia and fibula to restore proper alignment.
3. A patient fractures the weight bearing articular surface of the distal tibia and fibula due to a fall. The provider performs open treatment of the fracture, utilizing plates and screws to stabilize both the tibia and fibula.
4. A patient sustains a complex fracture in the weight bearing articular surface of the distal tibia and fibula. The provider performs open treatment of the fracture, using internal fixation on both the tibia and fibula to ensure proper healing.
5. A patient fractures the weight bearing articular surface of the distal tibia and fibula in a car accident. The provider performs open treatment of the fracture, securing both the tibia and fibula with wires and pins.
6. A patient presents with a tibial plafond fracture involving both the tibia and fibula. The provider performs open treatment of the fracture, utilizing plates and screws to stabilize the fractured fragments.