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The patient fell and twisted her right ankle. She is diagnosed with a medial malleolar fracture. In
the operating room, the surgeon makes an incision over the fracture site and first removes a
superficial fixation device (a pin) that had been placed in the patient's tibia twenty years ago
when she fractured her leg in an old injury. Then the surgeon realigns the fractured medial
malleolus and fixes it in place with screws. Assign the appropriate procedure code(s). Also
assign the appropriate modifier(s) to indicate the side of the body the procedure was done on.

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The patient fell and twisted her right ankle. She is diagnosed with .pdf

  • 1. The patient fell and twisted her right ankle. She is diagnosed with a medial malleolar fracture. In the operating room, the surgeon makes an incision over the fracture site and first removes a superficial fixation device (a pin) that had been placed in the patient's tibia twenty years ago when she fractured her leg in an old injury. Then the surgeon realigns the fractured medial malleolus and fixes it in place with screws. Assign the appropriate procedure code(s). Also assign the appropriate modifier(s) to indicate the side of the body the procedure was done on.