Question

PREOPERATIVE DIAGNOSIS : Right ankle triplane fracture.

POSTOPERATIVE DIAGNOSIS : Right ankle triplane fracture.

PROCEDURE : Open reduction and internal fixation (ORIF), right ankle triplane fracture.

ANESTHESIA : General endotracheal.

COMPLICATIONS : None.

SPECIMEN : None.

IMPLANT USED : Synthes 4.0 mm cannulated screws.

INDICATIONS FOR PROCEDURE :

The patient is a pleasant 15-year-old male who fell and sustained a right ankle triplane fracture. This was confirmed on both X-ray and CT scan. The indications for ORIF were explained to the patient, as well as the possible risks and complications, which include infection, bleeding, stiffness, hardware pain, the need for hardware removal, and there is no guarantee of a functional ambulatory result. The patient and family understood and wished to proceed.

PROCEDURE IN DETAIL :

The patient was brought back to the operating room and placed on an operating table, given a general anaesthetic without any complications, and given preoperative antibiotics per usual routine. He had the right lower extremity prepped and draped in the usual sterile fashion with alcohol prep followed by routine Betadine prep.
Under X-ray guidance, a pointed reduction clamp was placed from the anterolateral corner of the distal tibia to the medial side, and I reduced the triplane fracture. It was confirmed on both AP and lateral X-ray images the gap was reduced. The patient then had guidewires taken from the Synthes 4.0 mm cannulated screw set. One was placed medially along the epiphysis on the anterior half of the epiphysis and parallel to the joint to catch the lateral aspect of the epiphysis. One screw was placed above the physis from anterior to posterior to capture that spike. Once the wires were in the appropriate position, the length was measured and partially threaded 4.0 mm cancellous screws were selected so all threads were across the fracture site. The appropriate length screws were placed, confirmed by an X-ray to be in a good position. The fracture was anatomically reduced, and the ankle joint was anatomic. The patient had wounds copiously irrigated. The closure was done with interrupted horizontal mattress 3-0 nylon suture. The patient had a sterile compressive dressing applied, was placed into a three-sided posterior mould splint, was extubated, and brought to the recovery room in stable condition. There were no complications. There were no specimens. Sponge and needle counts were equal at the end of the case.

What are the CPT® and ICD-10-CM codes reported?

Answer 1

The CPT and ICD-10-CM codes for a right ankle triplane fracture treated with ORIF would pertain to open treatment of distal physeal fracture and triplane ankle fracture, respectively, with specific codes depending on detailed fracture classifications and treatment specifics.

Step-by-step explanation:

The student is asking for CPT (Current Procedural Terminology) and ICD-10-CM (International Classification of Diseases, Tenth Revision, Clinical Modification) codes for a right ankle triplane fracture that was treated with open reduction and internal fixation (ORIF). For the CPT code, given the provided information, you would use the specific code for open treatment of distal physeal fracture, which includes internal fixation when performed.

The exact code would depend on further specifics such as the type of fracture and method of fixation used. As for the ICD-10-CM, the appropriate code would reflect a triplane ankle fracture. Common codes for ankle fractures range from S82.8XXA for fracture of other parts of lower leg to S82.84XA for triplane fractures specifically.

An accurate selection requires careful review of the full details of the operative report and matching those details to the code descriptions in the CPT and ICD-10-CM manuals, which are updated annually, so it is important to ensure the version of the manual matches the year in which the service was provided.