Query: Revision of Ankle Syndesmosis Surgery
For an inadequately reduced ankle syndesmosis
from a prior ankle fracture and symptomatic
hardware, I performed the following through 3
separate incisions:
- Removal of a large amount of ankle hardware
- Exploration of the syndesmosis; curettage of
scar tissue at the syndesmosis
- Internal screw fixation of the syndesmosis.
I would appreciate assistance in coding the
above.
Greg Still, DPM
Estes Park, CO
Codingline Response: I would code this as:
CPT 27829 (open treatment of distal tibiofibular
joint disruption with or without internal or
external
fixation)
CPT 20680 (removal of hardware, deep)
The debridement and removal of the scar tissue
may be considered incidental to the repair. If,
however, a significant amount of work was done
(and documented), you could append a "-22"
modifier to the CPT 27829 procedure code, and
increase your fee accordingly.
For the removal of the symptomatic hardware, I
would add diagnosis code, ICD-9 996.78, for the
scar tissue and the surgery re-do, I would use a
late effect code, ICD-9 905.4, along with the
original diagnosis of ankle dislocation code,
ICD-9 837.0
Denise Paige, CPC
Long Beach, CA
