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Official Description

Closed treatment of proximal fibula or shaft fracture; without manipulation

© Copyright 2025 American Medical Association. All rights reserved.

Common Language Description

Closed treatment of a proximal fibula or fibular shaft fracture refers to a non-surgical method of managing a fracture located at the upper part of the fibula or along its shaft. This procedure is specifically indicated for cases where the fracture is either nondisplaced or minimally displaced, meaning that the bone fragments have not moved significantly from their original position. During this treatment, the physician does not manipulate the fracture fragments, which distinguishes it from other procedures that may involve realignment of the bones. To ensure proper diagnosis and treatment, radiographs, or X-rays, are obtained to confirm the presence of the fracture. Additionally, a neurovascular examination is conducted to assess the integrity of the nerves and blood vessels surrounding the injury site, ensuring that there are no complications that could affect healing. Following the assessment, a cast or brace is applied to immobilize the fracture, providing stability and support during the healing process. This procedure is essential for promoting proper recovery while minimizing the risk of further injury or complications.

© Copyright 2025 Coding Ahead. All rights reserved.

1. Indications

Closed treatment of a proximal fibula or shaft fracture is indicated for the following conditions:

  • Nondisplaced Fracture The procedure is performed when the fracture fragments remain in their normal anatomical position, requiring no manipulation.
  • Minimally Displaced Fracture This treatment is also appropriate for fractures where the bone fragments have shifted slightly but do not require realignment.

2. Procedure

The closed treatment of a proximal fibula or shaft fracture involves several key procedural steps:

  • Step 1: Radiographic Confirmation Initially, the physician obtains radiographs to confirm the presence of the fracture. This imaging is crucial for determining the type and extent of the fracture, guiding the subsequent treatment plan.
  • Step 2: Neurovascular Examination Following the imaging, a thorough neurovascular examination is conducted. This assessment checks the function of the nerves and blood vessels in the area surrounding the fracture to ensure that there are no injuries that could complicate healing.
  • Step 3: Application of Immobilization Device Once the fracture is confirmed and the neurovascular status is deemed intact, the physician applies a cast or brace to immobilize the fracture. This immobilization is essential for stabilizing the fracture and allowing for proper healing without the risk of further displacement.

3. Post-Procedure

After the closed treatment procedure, the patient is typically monitored for any signs of complications. The immobilization device, whether a cast or brace, is usually kept in place for a specified duration to ensure adequate healing. Patients may be advised on follow-up appointments to assess the healing process through additional radiographs. It is important for patients to adhere to any prescribed activity restrictions during the recovery period to avoid jeopardizing the healing of the fracture.

Short Descr TREATMENT OF FIBULA FRACTURE
Medium Descr CLTX PROX FIBULA/SHFT FX W/O MANJ
Long Descr Closed treatment of proximal fibula or shaft fracture; without manipulation
Status Code Active Code
Global Days 090 - Major Surgery
PC/TC Indicator (26, TC) 0 - Physician Service Code
Multiple Procedures (51) 2 - Standard payment adjustment rules for multiple procedures apply.
Bilateral Surgery (50) 1 - 150% payment adjustment for bilateral procedures applies.
Physician Supervisions 09 - Concept does not apply.
Assistant Surgeon (80, 82) 1 - Statutory payment restriction for assistants at surgery applies to this procedure...
Co-Surgeons (62) 0 - Co-surgeons not permitted for this procedure.
Team Surgery (66) 0 - Team surgeons not permitted for this procedure.
Diagnostic Imaging Family 99 - Concept Does Not Apply
APC Status Indicator Procedure or Service, Multiple Reduction Applies
ASC Payment Indicator Surgical procedure on ASC list in CY 2007; payment based on OPPS relative payment weight.
Type of Service (TOS) 2 - Surgery
Berenson-Eggers TOS (BETOS) P6B - Minor procedures - musculoskeletal
MUE 1
CCS Clinical Classification 147 - Treatment, fracture or dislocation of lower extremity (other than hip or femur)
RT Right side (used to identify procedures performed on the right side of the body)
LT Left side (used to identify procedures performed on the left side of the body)
54 Surgical care only: when 1 physician or other qualified health care professional performs a surgical procedure and another provides preoperative and/or postoperative management, surgical services may be identified by adding modifier 54 to the usual procedure number.
50 Bilateral procedure: unless otherwise identified in the listings, bilateral procedures that are performed at the same session, should be identified by adding modifier 50 to the appropriate 5 digit code. note: this modifier should not be appended to designated "add-on" codes (see appendix d).
51 Multiple procedures: when multiple procedures, other than e/m services, physical medicine and rehabilitation services or provision of supplies (eg, vaccines), are performed at the same session by the same individual, the primary procedure or service may be reported as listed. the additional procedure(s) or service(s) may be identified by appending modifier 51 to the additional procedure or service code(s). note: this modifier should not be appended to designated "add-on" codes (see appendix d).
55 Postoperative management only: when 1 physician or other qualified health care professional performed the postoperative management and another performed the surgical procedure, the postoperative component may be identified by adding modifier 55 to the usual procedure number.
58 Staged or related procedure or service by the same physician or other qualified health care professional during the postoperative period: it may be necessary to indicate that the performance of a procedure or service during the postoperative period was: (a) planned or anticipated (staged); (b) more extensive than the original procedure; or (c) for therapy following a surgical procedure. this circumstance may be reported by adding modifier 58 to the staged or related procedure. note: for treatment of a problem that requires a return to the operating/procedure room (eg, unanticipated clinical condition), see modifier 78.
59 Distinct procedural service: under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-e/m services performed on the same day. modifier 59 is used to identify procedures/services, other than e/m services, that are not normally reported together, but are appropriate under the circumstances. documentation must support a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual. however, when another already established modifier is appropriate it should be used rather than modifier 59. only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used. note: modifier 59 should not be appended to an e/m service. to report a separate and distinct e/m service with a non-e/m service performed on the same date, see modifier 25.
78 Unplanned return to the operating/procedure room by the same physician or other qualified health care professional following initial procedure for a related procedure during the postoperative period: it may be necessary to indicate that another procedure was performed during the postoperative period of the initial procedure (unplanned procedure following initial procedure). when this procedure is related to the first, and requires the use of an operating/procedure room, it may be reported by adding modifier 78 to the related procedure. (for repeat procedures, see modifier 76.)
79 Unrelated procedure or service by the same physician or other qualified health care professional during the postoperative period: the individual may need to indicate that the performance of a procedure or service during the postoperative period was unrelated to the original procedure. this circumstance may be reported by using modifier 79. (for repeat procedures on the same day, see modifier 76.)
80 Assistant surgeon: surgical assistant services may be identified by adding modifier 80 to the usual procedure number(s).
AG Primary physician
AQ Physician providing a service in an unlisted health professional shortage area (hpsa)
AS Physician assistant, nurse practitioner, or clinical nurse specialist services for assistant at surgery
CR Catastrophe/disaster related
ET Emergency services
FS Split (or shared) evaluation and management visit
GC This service has been performed in part by a resident under the direction of a teaching physician
GV Attending physician not employed or paid under arrangement by the patient's hospice provider
GW Service not related to the hospice patient's terminal condition
X2 Continuous/focused services: for reporting services by clinicians whose expertise is needed for the ongoing management of a chronic disease or a condition that needs to be managed and followed with no planned endpoint to the relationship; reporting clinician service examples include but are not limited to: a rheumatologist taking care of the patient's rheumatoid arthritis longitudinally but not providing general primary care services
X4 Episodic/focused services: for reporting services by clinicians who provide focused care on particular types of treatment limited to a defined period and circumstance; the patient has a problem, acute or chronic, that will be treated with surgery, radiation, or some other type of generally time-limited intervention; reporting clinician service examples include but are not limited to, the orthopedic surgeon performing a knee replacement and seeing the patient through the postoperative period
XS Separate structure, a service that is distinct because it was performed on a separate organ/structure
XU Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service
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