Open surgical repair of a posterior malleolus fracture, with internal fixation (screws, plates, or both) applied as needed to restore alignment and stability.

Verified May 8, 2026 · 5 sources ↓

Medicare: $675.70
Work RVU: 9.89
Global, days: 90
Region: Foot & ankle

Drawn from CMSAAPCGenhealthEmedny

Documentation requirements

What must appear in the operative or office note to support the claim.

Source · Editorial brief grounded in 5 cited references ↓

Imaging confirming posterior malleolus fracture with documentation of displacement, fragment size, or articular involvement that justifies open treatment over closed management
Operative note identifying the surgical approach by name (posterolateral, posteromedial, direct posterior) — notes that say 'standard approach' flag on audit
Explicit description of fracture reduction technique and confirmation of alignment achieved intraoperatively
Type, size, and placement of all internal fixation hardware used (screws, plates, washers), or documentation that fixation was not placed and rationale
Intraoperative fluoroscopy findings if used, even though guidance is bundled — confirms fracture reduction quality
For multi-fragment or trimalleolar injuries, separate operative note sections addressing each malleolus treated to support additional fracture codes billed with modifier 51

Applicable modifiers

Modifiers commonly billed with this code.

Source · AMA CPT modifier descriptors · CMS NCCI Policy Manual

22 Increased complexity 51 Multiple procedures 52 Reduced services 59 Distinct service 62 Co-surgeons 76 Repeat, same physician 77 Repeat, another physician 78 Unplanned return — related 79 Unrelated during global 80 Assistant surgeon LT Left side RT Right side

What this code covers

Source · Editorial summary grounded in 5 cited references ↓

CPT 27769 covers open treatment of a posterior malleolus fracture — the triangular fragment at the back of the distal tibia that forms part of the ankle mortise. The surgeon makes a posterior or posterolateral incision, directly visualizes the fracture, reduces displaced fragments, and stabilizes the construct with internal fixation hardware when indicated. Because the posterior malleolus contributes to ankle joint congruity and resists posterior talar subluxation, displacement thresholds (commonly >25–33% articular involvement or >2 mm step-off) typically drive the decision toward open fixation over closed management.

This code sits within the ankle fracture family alongside 27767 (closed, no manipulation) and 27768 (closed, with manipulation). When the posterior malleolus fracture is part of a bimalleolar or trimalleolar injury pattern, additional fracture codes — such as 27766 for the medial malleolus — may be reported with modifier 51. The 90-day global period covers the day-before visit, the operative session, and all routine post-op care through day 90. Anything unrelated to the fracture billed in that window requires modifier 24 or 25.

Casting, splinting, and strapping applied at the time of surgery are bundled into 27769 per NCCI policy and cannot be billed separately. Fluoroscopic guidance used intraoperatively is similarly bundled — do not add 77002 or 77012 unless a separately distinct procedure on a different anatomic site justifies it.

RVU & reimbursement

Component RVUs and Medicare national rate. Actual payment varies by GPCI locality.

Source · CMS Physician Fee Schedule, RVU26A · January 2026

Work RVU vs. total RVU

The work RVU (9.89) is the surgeon's own effort — the figure physician pay and productivity targets are built on. The total RVU (20.23) adds practice overhead and malpractice, and is what drives the Medicare payment below.

Work RVU	9.89
Practice expense RVU	8.37
Malpractice RVU	1.97
Total RVU	20.23
Medicare national rate	$675.70
Global period	90 days

Payment by site of service

Medicare pays different rates by setting. HOPD typically pays substantially more than ASC for the same procedure.

Source · CMS OPPS Addendum B·ASC HCPCS payment rates·2026

Setting	Medicare rate (national)
Office (PFS non-facility) Procedure performed in physician's office	$675.70
HOPD (APC 5114) Hospital outpatient department	$7,413.38
ASC (PI J8) Ambulatory surgical center (freestanding)	$4,682.29

Common denial reasons

The recurring reasons claims for CPT 27769 get rejected.

Source · Editorial brief grounded in CMS NCCI edits, AAOS coding appeals, and cited references ↓

Casting or splinting billed separately on the same date — bundled into 27769 per NCCI; no modifier unlocks this pairing
Missing or vague laterality — payers require LT or RT; a note that only says 'right ankle' without the modifier on the claim line triggers automated denial
Concurrent malleolus fracture codes (e.g., 27766) submitted without modifier 51, causing multiple-procedure reduction to be misapplied or one code to be denied outright
Lack of medical necessity documentation for open versus closed treatment — if the operative note doesn't quantify displacement or articular step-off, reviewers deny open fixation as not medically necessary
Global period violations — E&M visits during the 90-day window billed without modifier 24, rejected as included in the surgical package

Frequently asked questions

Source · Generated from the editorial pipeline, verified against 5 cited references ↓

01Can I bill 27769 with 27766 for a trimalleolar fracture?

Yes. When you treat both the posterior and medial malleolus in the same session, report 27769 as the primary code and 27766 with modifier 51. If the lateral malleolus is also fixed, add the appropriate fibula fracture code with modifier 51 as well. Each code needs its own documentation section in the operative note.

02Is intraoperative fluoroscopy separately billable with 27769?

No. NCCI policy bundles intraoperative fluoroscopic guidance into open fracture repair codes. Do not add 77002 or 77012 for guidance used during the posterior malleolus fixation itself.

03Can I bill a cast or splint applied at the end of the procedure?

No. Per NCCI Chapter 4, casting, splinting, and strapping applied during or after open fracture repair are included in the fracture code. Billing 29515 or similar codes separately will be denied without any modifier fix available.

04What modifier applies if a second surgeon assists with the fixation?

Use modifier 80 for a physician assistant-at-surgery, or AS if an NP or PA assists. For a co-surgeon sharing distinct portions of the procedure, modifier 62 applies and both surgeons bill 27769-62 with separate operative reports documenting each surgeon's contribution.

05How does the 90-day global period affect post-op billing?

The 90-day global covers all routine post-op visits, dressing changes, suture removal, and fracture checks through day 90. If you see the patient for an unrelated condition (e.g., a new injury or medical problem), bill the E&M with modifier 24. If you perform a new, unrelated procedure during the global window, use modifier 79.

06When is modifier 22 appropriate for 27769?

Use modifier 22 when the procedure is substantially more complex than typical — for example, severe comminution requiring advanced fixation constructs, significant soft tissue compromise complicating the approach, or revision of a failed prior fixation. Attach a letter of medical necessity explaining the added work; expect payer review before payment.

Sources & references

Editorial content was developed using the following public sources. Last verified May 8, 2026.

Mira Scribe

Mira's AI scribe captures the posterior malleolus fracture pattern, fragment size relative to the articular surface, degree of displacement or step-off, the named surgical approach, reduction technique, and all fixation hardware placed. That detail prevents the two most common audit flags for 27769: operative notes that don't justify open treatment over closed management, and hardware documentation gaps that trigger implant-cost audits.

See how Mira captures CPT 27769 documentation