01/03/2003    Vincent Gramuglia, DPM

Talar Dome Fracture Coding

Query: Talar Dome Fracture Coding
From: Vincent Gramuglia, DPM

I recently treated a patient with a
posterior, medial talar dome fracture. The
treatment included open reduction internal
fixation of the large bone fragment after
curettage of the necrotic crater and use of
Grafton bone gel. The procedure involved a
medial maleolar osteotomy in order to gain
exposure to the fracture fragment. Because of
scope of practice issues in New York, an
orthopedic surgeon colleague assisted me on the
case.
How should this procedure be coded? Should
particular modifiers be used for co-surgeons, or
do we bill this as surgeon, surgical assistant?
Is the medial maleolar osteotomy coded
additionally? Thanks for any help.

Vincent Gramuglia, DPM
Bronx, NY

------Codingline-L Responses:

Were you actually working as co-surgeons (as
defined), or was the ortho surgeon acting as the
assistant surgeon? You mentioned 'because of the
scope of practice issues in New York, an ortho
surgeon assisted'. Was the orthopedist actually
the surgeon on the tibial malleolar osteotomy?
The use of the Grafton bone gel would be
considered inherent to an open reduction internal
fixation (ORIF) procedure, such as exampled by
CPT 28445 ("open treatment of talus fracture,
with or without internal or external
fixation").
You stated that it was needed to perform an
malleolar osteotomy to get to the talar dome
fracture fragments. In this case, the osteotomy
is generally considered inherent to the ORIF.
Chapter 1 of the NCCI edits state, "Surgical
approach, including identification of anatomical
landmarks, incision, evaluation of the surgical
field, simple debridement of traumatized tissue,
lysis of simple adhesions, isolation of
neurovascular, muscular (including stimulation
for identification), bony or other structures
limiting access to surgical field." Since it
states 'simple' debridement, the AAOS has stated
that when reporting CPT 28445, excisional
debridement codes CPT 11010-11012 may be reported
separately IF documentation supports their use.

Margie Vaught, CPC
Ellensburg, WA

-----

Necrotic crater? Sounds like this may have
been a pathologic fracture, at least to my
layperson's ear. At any rate, let's address the
fracture first.
Because osteotomy of the medial malleolus is
a recognized part of the surgical approach in
open treatment of a talar body fracture, I'm sure
this was taken into consideration when the RVU
was established for CPT 28445 (open treatment of
talus fracture, with or without internal or
external fixation). With that in mind, I would
report CPT 28445 for the fractuare treatment.

As far as the curettage of the necrotic
crater is concerned, it's difficult to make a
firm recommendation without reviewing the
operative report, however, if this is the result
of a pathologic process, you might consider
reporting CPT 28100 (excision or curettage of
bone cyst of benign tumor, talus or calcaneus) as
a secondary procedure.
No additional code is reported for the use
of synthetic graft material.

Heidi Stout CPC, CCS-P
University Orthopaedic Associates
New Brunswick, NJ

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