AHA Coding Clinic® for HCPCS - 2021 Issue 1; For Your Information

Syndesmotic injury repair

A patient with a left displaced bimalleolar ankle fracture, with syndesmotic injury underwent an open reduction internal fixation (ORIF) of both the fracture and syndesmotic injury. A lateral incision was made to the distal fibula down to the fracture site where disruption of the syndesmosis was noted. A locking plate was secured to reduce the fibula. The incision was then extended to the medial side and the medial malleolus into the tibia was reduced. Once the fracture was reduced, the syndesmosis was reduced using by drilling across the tibia, pulling an Invisiknot suture through and securing with a button. Is it appropriate to assign an additional code for the reduction of the syndesmotic injury or is it inherent to the bimalleolar ORIF? ...

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