27786 CPT code for specialist visit

[jobfedron]

Hello,

Thanks for the great work you guys do.
Heres my situation:
Was out fo state and slipped on the stairs and broke fibula.
Went to ER and the doc took an xray, gave me a walking boot and recommended me to see an ortho in my home town.
Went to the ortho and i gave him the xray, he touched my ankle to see where it hurts and he said i will need a surgery ( open reduction coded as 27792 which was done last week).
This visit was coded as follows,
Procedure Code: 99204 -- office visit
Procedure Code: 27786 -- Frac Treatment/Leg/Ankle
Does this seem right? I thought 27786 is closed reduction treatment (which my understanding is a treatment like open reduction rather than a checkup)

TLDR: Is 27786 the right code if doctor just looked at the xray and suggested an open reduction surgery (CPT code 27792)?

[Michele]

So the 99204 is because you hadn't ever seen that dr (or at least not in the last 3 years).  The 27786 is for "closed treatment of distal fibular fracture".  I know you stated he "touched" your ankle to see if it hurts, then recommended surgery.  Since I wasn't in the room I really can't be sure, but he may have read the xray, physically examined your foot by touching it, then made the decision that surgery was required.  So technically he did do a closed treatment of the fracture, but that wasn't enough to correct the issue, so he recommended surgery.   A summary of the 27786 code:  "In this procedure, the provider treats a distal fracture of the fibula, or a break in the end of the fibula bone of the leg, which does not require manipulation.
"

If you do not believe he did that description you can call the office and ask.  It is possible that the dr intended to do a closed treatment, but then changed his mind to do surgery, but the billing department thought he did the closed reduction and it was billed in error.  There is nothing wrong with calling the office to make sure it was billed correctly.

[jobfedron]

The Dr did examine my ankle and checked the xray, which means the billing was correct. I just wanted to get a 2nd opinion.
Thanks Michele for clearing this up.

[kristin]

The billing is not necessarily correct.

Part of billing a fracture care code (in this case, the 27786) is that "restorative treatment" is part of the code, and that needs to be performed by the doctor, even if it is a closed "treatment" without manipulation. The key word here is "treatment". The doctor reviewing your x-rays, touching your ankle, and deciding you need surgery is not "restorative treatment", or "treatment". You already got a CAM Walker from the ER doc. Did the second doc who billed the 27786 splint your leg? Do anything else that would be considered "treatment"? If not, they can't bill a 27786.

The second doc's billing should have been a 99204 (or a 99203, to be honest) for the first visit, and then a 27792 once you had surgery.

Definitely call the office as Michele says, and get this corrected.