PCS Coding for Ankle Fracture - Look Deeper Into the Codes!

May 25th, 2021 - Christine Woolstenhulme, QCC, QMCS, CPC, CMRS

Categories: Hospital ICD-10-PCS

If you're looking for ankle fractures in ICD-10-PCS, you may need to look a little deeper. Let's take a look at coding an ankle fracture such as a trimalleolar fracture. PCS coding can be confusing as it is nothing like CPT coding; with CPT we can simply code an ankle fracture.

With ICD-10-PCS if a provider is used to just documenting a bimalleolar or trimalleolar fracture like the CPT codes below, additional documentation will be required to understand the exact bones and location involved to properly code with ICD-10-PCS.

27808 Closed treatment of bimalleolar ankle fracture
27816 Closed treatment of trimalleolar ankle fracture

Since the ankle joint is where the tibia and fibula meet the Talus this is where ankle fractures happen; you would code three fractures if all three different bones were involved in the treatment of a trimalleolar fracture. When using ICD-10-PCS codes, you are coding the bones, not the joint. Therefore, you will not find a code for a fracture of the ankle; you may now need a combination of (body parts) bones instead of just one code. Fusion of an ankle is done on the joint, not the bone, and is still coded as the ankle joint.

0SGF04Z - Fusion of Right Ankle Joint with Internal Fixation Device, Open Approach

If there is a displaced ankle joint, you will code the root of the procedure and the approach; this would be in addition to any fractures.

In the examples below, the repair or release is the root procedure for a displaced ankle joint.

0SQF3ZZ - Repair Right Ankle Joint, Percutaneous Approach
0SNFXZZ - Release Right Ankle Joint, External Approach

What are the bones included in the Tarsal?

If the talus bone is a part of the fracture, you will not find a code specifically for the Talus. ICD-10-PCS has grouped the seven short bones in the foot and ankle area together, collectively known as the tarsus. Therefore, a fracture of the Talus is coded under repair of Tarsal.

0QQLXZZ - Repair Right Tarsal, External Approach

There are seven bones included in the tarsal bones with ICD-10-PCS coding.

talus.
calcaneus.
navicular.
cuboid.
lateral cuneiform.
intermediate cuneiform.
medial cuneiform.

Before we go any further, let's understand the Characters of ICD-10-PCS, there are seven characters, and each character identifies a specific part of the code as indicated in the table.

1-Section

2 Body System

3 Root Operation

4 Body Part

5 Approach

6 Device

7 Qualifier

In the musculoskeletal system, the fourth character represents the body part the procedure was performed on; the tibia in the codes below are represented here by the character G in the fourth position.

0QQG0ZZ Repair Right Tibia, Open Approach

0QQG3ZZ Repair Right Tibia, Percutaneous Approach

0QQG4ZZ Repair Right Tibia, Percutaneous Endoscopic Approach

0QQGXZZ Repair Right Tibia, External Approach

Several Approaches

There are several approaches used when coding fractures with ICD-10-PCS. The approach is the fifth character, notice the approach in the examples, O, 3, 4, and X.

0QQG0ZZ Repair Right Tibia, Open Approach
0QQG3ZZ Repair Right Tibia, Percutaneous Approach
0QQG4ZZ Repair Right Tibia, Percutaneous Endoscopic Approach
0QQGXZZ Repair Right Tibia, External Approach

Important NOTE: An external approach is the same as a closed treatment according to the ICD-10-PCS guidelines, B5.3b Procedures performed indirectly by the application of external force through the intervening body layers are coded to the approach, external.

Example: Closed reduction of fracture is coded to the External approach.

Seven ICD-10-PCS Medical and Surgical Approaches

Not all of the following approaches apply to fractures; however, there are seven different approaches used in the medical and surgical section.

Approach	Fifth Character	Example
Open	0	0QQG0ZZ Repair Right Tibia, Open Approach
Percutaneous	3	0SQF3ZZ - Repair Right Ankle Joint, Percutaneous Approach
Percutaneous endoscopic	4	0QQG4ZZ Repair Right Tibia, Percutaneous Endoscopic Approach
Via natural or artificial opening	7	0UDB7ZZ, dilation and curettage
Via natural or artificial opening endoscopic	8	0KN84ZZ Release Left Upper Arm Muscle, Percutaneous Endoscopic Approach
Via natural or artificial opening with percutaneous endoscopic assistance	F	079F8ZZ Drainage of Right Lower Extremity Lymphatic, Via Natural or Artificial Opening Endoscopic
External	X	0QQGXZZ Repair Right Tibia, External Approach

Fixation Charges

When coding a fixation performed with the fracture, you need to remember; if the fixation was done internally it may be included with CPT and the external fixation is coded separately using the codes below.

20690 - Application of a uniplane (pins or wires in 1 plane), unilateral, external fixation system
20692 - Application of a multiplane (pins or wires in more than 1 plane), unilateral, external fixation system (eg, Ilizarov, Monticelli type)
20696- Application of multiplane (pins or wires in more than 1 plane), unilateral, external fixation with stereotactic computer-assisted adjustment

With ICD-10-PCS, you need to look for the root operation that involves a device, the following are root operations that involve a device.

Insertion	Root operation H
Replacement	Root operation R
Supplement	Root operation U
Change	Root operation 2
Removal	Root operation P
Revision	Root operation W

Be sure you understand the definition of each root operation for example; "Replacement" is not used to replace an External Fixation Device, even though it sounds like it should. Look at what the PCS Reference manual states:

Replacement— Root operation R

Definition: Putting in or on biological or synthetic material that physically takes the place and/or function of all or a portion of a body part

Explanation: The body part may have been taken out or replaced, or may be taken out, physically eradicated, or rendered nonfunctional during the Replacement procedure. A

Removal procedure is coded for taking out the device used in a previous replacement.

Examples: Total hip replacement, bone graft, free skin graft.

The objective of procedures coded to the root operation Replacement is to put in a device that takes the place of some or all of a body part. Replacement encompasses a wide range of procedures, from joint replacements to grafts of all kinds.

Therefore, since "Replacement" is not used to replace wires or pins, you will use "Removal" and "Insertion" procedures for removing and replacing a device used in a previous replacement procedure.

Operation P - Removal

0QPK04Z Removal of Int Fix from L Fibula, Open Approach

Operation H - Insertion

0QHK04Z Insertion of Int Fix into L Fibula, Open Approach

If just the insertion was done you would find the code under root operation H.

PCS does offer "Fusion" (Operation G). Therefore, a fusion of the ankle joint does have its own code and can be found in the lower joints section representing the fourth character.

0SGF05Z - Fusion of Right Ankle Joint with External Fixation Device, Open Approach

In PCS, the application of fixation of a bone has a code for each bone. You will find these codes under insertion; it is not called a fixation with PCS Coding. Remember, if you are working on a fracture, you are working with the bone, not the joint. Fusions happen on joints; insertions for a fracture are coded to the specific bone and will be found in the section under lower bones.

We now understand that with PCS, the root operations are different than CPT; for fractures, we are coding the bone, not the joint, the Talus, along with six other bones are included with the Tarsal bone. The approach on a joint and the root operation is is not a replacement but removal and insertion.

With what you have learned in this article, find the following codes by constructing them one character at a time.

Fusion of Right Ankle Joint with Internal Fixation Device, Open Approach
Repair Right Tibia, Open Approach
Removal of Internal Fixation device from L Fibula, Open Approach
Fusion of Right Ankle Joint with External Fixation Device, Open Approach

Codes

0SGF04Z, 0QQG0ZZ, 0QPK04Z, 0SGF05Z

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