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2025 CPT code 27822

Open treatment of trimalleolar ankle fracture; internal fixation of medial and/or lateral malleolus; without fixation of posterior malleolus.

Refer to the CPT manual for comprehensive coding guidelines and instructions regarding fracture and dislocation procedures.Specific guidance is also available within the musculoskeletal section of the CPT codebook.

Modifiers may apply based on specific circumstances of the procedure.For example, modifier 51 (multiple procedures) might be used if other procedures were performed concurrently, and modifier 76 (repeat procedure by the same physician) may be used if a re-reduction was performed by the same physician.

Medical necessity for this procedure is established by the presence of a displaced or unstable trimalleolar ankle fracture.The need for surgical intervention is typically based on the degree of displacement, the risk of malunion, and the potential impact on ankle function.

The orthopedic surgeon is responsible for the pre-operative planning, surgical procedure, and post-operative care. This includes patient evaluation, surgical incision and exploration of the fracture, reduction of the fracture fragments, internal fixation, wound closure, and application of a cast or brace. Post-operative imaging and follow-up care are also within their responsibility.

IMPORTANT If fixation of the posterior malleolus is performed, a different CPT code should be used.Additional codes may be necessary to report other services such as separate incisions for bone grafts or complex repairs.

In simple words: This code represents a surgery to fix a broken ankle.The doctor will make an incision, realign the broken bones, and use plates, screws, or pins to hold two of the three broken parts together. The back part of the ankle may not be fixed with hardware in this particular procedure.

This CPT code, 27822, describes the open surgical treatment of a trimalleolar ankle fracture.The procedure involves internal fixation (using plates, screws, wires, or pins) of the medial and/or lateral malleoli.Crucially,fixation of the posterior malleolus is not included in this specific code. This surgical intervention is typically indicated for unstable fractures requiring additional support for proper alignment and healing.

Example 1: A 35-year-old male sustains a trimalleolar ankle fracture in a skiing accident.Open reduction and internal fixation of the medial and lateral malleoli is performed using plates and screws. The posterior malleolus is treated non-operatively., A 60-year-old female falls and fractures her ankle, resulting in a displaced trimalleolar fracture.Open reduction and internal fixation with plates and screws are used to stabilize the medial and lateral malleoli. The posterior fragment is stable enough to not require fixation., A 22-year-old male athlete suffers a severe ankle injury during a football game. The injury is diagnosed as a trimalleolar fracture with significant displacement. Open reduction is performed. The medial and lateral malleoli are stabilized using screws and plates.The posterior malleolus is managed non-operatively due to its stable position.

* Pre-operative diagnostic imaging (X-rays) showing the trimalleolar fracture.* Operative report detailing the surgical approach, reduction techniques, internal fixation materials used, and assessment of the posterior malleolus.* Post-operative imaging (X-rays) to confirm fracture alignment and fixation stability.* Detailed description of any complications encountered during or after the surgery.

** This code specifically excludes fixation of the posterior malleolus. If fixation of the posterior malleolus is performed, another, more comprehensive, CPT code should be utilized.Always refer to the most current CPT manual for the most accurate coding guidelines and updates.

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