2025 CPT code 27758
(Active) Effective Date: N/A Revision Date: N/A Surgery - Fracture and/or Dislocation Procedures on the Leg (Tibia and Fibula) and Ankle Joint Musculoskeletal System Feed
Open treatment of a tibial shaft fracture, with or without fibular fracture, using plates and screws, with or without cerclage.
Modifiers may be applicable depending on the specific circumstances, such as modifier 54 (Surgical Care Only) if the provider does not perform the postoperative care,modifier 76 (Repeat Procedure by the Same Physician) if the procedure is repeated,and others as deemed appropriate.
Medical necessity for this procedure is established by the presence of a displaced tibial shaft fracture that is not amenable to closed reduction.The procedure is necessary to restore anatomical alignment, stability, and function of the leg, and to alleviate pain.Documentation must support the clinical indication for an open procedure over alternative, less invasive treatments.
The orthopedic surgeon or qualified healthcare professional is responsible for the entire procedure, including pre-operative planning, surgical technique, post-operative care, and follow-up management within the global period.
In simple words: The doctor surgically repairs a broken bone in the shin (tibia), which might also include a broken bone in the smaller bone next to it (fibula).This involves opening the skin, putting the broken pieces back together, and using plates and screws to hold them in place.Sometimes, wires are also used for extra support. This helps the bones heal properly and reduces pain.
This CPT code, 27758, describes the open surgical treatment of a fracture in the tibial shaft, which may or may not involve the fibula.The procedure involves surgical exposure of the fracture site, reduction of the fracture fragments, and internal fixation using plates and screws.Cerclage wiring may also be utilized to further stabilize the fracture.The procedure is performed to restore proper alignment and stability to the bone, facilitating healing and pain relief.Treatment of any associated fibular fracture is included and not separately reported.
Example 1: A patient presents with a displaced tibial shaft fracture after a motor vehicle accident.Open reduction and internal fixation with plate and screw placement is performed.No fibular fracture is present., A patient sustains a tibial shaft fracture with a comminuted fibular fracture during a skiing accident.Open reduction and internal fixation with plate, screw, and cerclage wiring are performed to stabilize both bones. , A patient with an open tibial shaft fracture undergoes open reduction and internal fixation.Significant soft tissue damage necessitates extensive wound debridement and skin grafting, which would be coded separately.
* Pre-operative imaging (x-rays) demonstrating the fracture.* Operative report detailing the surgical technique, including the type and size of plates and screws used.* Post-operative imaging to confirm fracture reduction and hardware placement.* Documentation of the patient’s neurovascular status pre- and post-operatively.* Anesthesia record.
** This code encompasses various surgical techniques for open treatment of tibial shaft fractures.The specific type of plates, screws, and other hardware is not explicitly coded.
- Revenue Code: P3D (Major Procedure, Orthopedic - Other)
- RVU: This information varies by payer and geographic location. Consult the relevant fee schedule for the specific RVUs and reimbursement rates.
- Global Days: 90-day global period.Follow-up visits, cast changes, and routine x-rays within this period are not separately billable.
- Payment Status: Active
- Modifier TC rule: Not applicable.
- Fee Schedule: Historical fee schedule information can be accessed through various payer-specific databases.These values are subject to change and may vary based on location and other factors.
- Specialties:Orthopedic Surgery, Trauma Surgery
- Place of Service:Inpatient Hospital, Ambulatory Surgical Center, Hospital Outpatient