Closed treatment of a trimalleolar ankle fracture requiring manipulation to achieve reduction
Verified May 8, 2026 · 7 sources ↓
- Medicare
- $584.85
- Work RVU
- 5.55
- Global, days
- 90
- Region
- Foot & ankle
Documentation requirements
What must appear in the operative or office note to support the claim.
Source · Editorial brief grounded in 7 cited references ↓
- Identify all three malleoli involved (lateral, medial, and posterior) by name in the operative or procedure note
- Confirm closed treatment — no incision made, no internal fixation placed
- Document that manipulation was performed and describe the technique used to achieve reduction
- Record pre- and post-reduction imaging (X-ray) with interpretation confirming fracture pattern and alignment
- Note the type of immobilization applied after reduction (cast, splint, boot) and laterality (left vs. right)
- Document anesthesia used if reduction was performed under sedation or regional block
Applicable modifiers
Modifiers commonly billed with this code.
Source · AMA CPT modifier descriptors · CMS NCCI Policy Manual
What this code covers
Source · Editorial summary grounded in 7 cited references ↓
27818 covers closed (non-incisional) reduction of a trimalleolar ankle fracture — all three malleoli involved (lateral, medial, and posterior) — where manipulation is required to achieve acceptable alignment. No internal fixation is placed under this code; the fracture is managed externally, typically with casting or splinting after reduction. This is the manipulation-required counterpart to 27816, which covers the same fracture pattern without manipulation.
The 90-day global period covers the day-before visit, the procedure itself, and all routine fracture management through day 90 — including cast changes, splint adjustments, and standard follow-up imaging reads. New problems or unrelated E/M services need modifier 24. A staged procedure within the global (e.g., planned conversion to open fixation) requires modifier 58.
Code selection hinges on fracture pattern and treatment method. If the surgeon makes an incision or places hardware, 27822 or 27823 applies instead. If only two malleoli are involved, look to 27808/27810 (bimalleolar). Document the number of malleoli fractured and confirm closed treatment without fixation — payers and auditors will scrutinize this distinction.
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 (5.55) is the surgeon's own effort — the figure physician pay and productivity targets are built on. The total RVU (17.51) adds practice overhead and malpractice, and is what drives the Medicare payment below.
| Work RVU | 5.55 |
| Practice expense RVU | 10.71 |
| Malpractice RVU | 1.25 |
| Total RVU | 17.51 |
| Medicare national rate | $584.85 |
| 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 | $584.85 |
HOPD (APC 5112) Hospital outpatient department | $1,642.82 |
ASC (PI A2) Ambulatory surgical center (freestanding) | $872.87 |
Common denial reasons
The recurring reasons claims for CPT 27818 get rejected.
Source · Editorial brief grounded in CMS NCCI edits, AAOS coding appeals, and cited references ↓
- Upcoding flag: operative note documents fewer than three malleoli involved, contradicting trimalleolar code selection
- Bundling denial when 27818 is billed same-day as open fixation codes (27822/27823) without supporting documentation that distinct fracture events occurred
- Missing manipulation documentation — payers deny 27818 over 27816 when the note lacks explicit description of reduction maneuver
- Modifier missing for services billed during the 90-day global period of a prior ankle procedure
- Laterality not specified — claims lacking LT or RT modifier rejected by many commercial payers and some MACs
Frequently asked questions
Source · Generated from the editorial pipeline, verified against 7 cited references ↓
01What distinguishes 27818 from 27816?
02If the surgeon places percutaneous pins or screws during a closed trimalleolar reduction, does 27818 still apply?
03When is 27822 or 27823 used instead of 27818?
04Can 27818 be billed bilaterally?
05What happens if open fixation is planned after initial closed reduction under 27818?
06Does the 90-day global include post-reduction X-rays?
07How should a same-day E/M visit be handled if the fracture is diagnosed and reduced in the office on the same encounter?
Sources & references
Editorial content was developed using the following public sources. Last verified May 8, 2026.
- 01CMS Physician Fee Schedule 2026
- 02aapc.comhttps://www.aapc.com/codes/cpt-codes/27818
- 03findacode.comhttps://www.findacode.com/cpt/27818-cpt-code.html
- 04aapc.comhttps://www.aapc.com/codes/coding-newsletters/my-orthopedic-coding-alert/ankles-asking-6-questions-clear-up-your-ankle-fracture-coding-confusion-144598-article
- 05abos.orghttps://www.abos.org/wp-content/uploads/2019/12/sports-cpt-updated.pdf
- 06aaoms.orghttps://aaoms.org/wp-content/uploads/2024/04/Trauma_CodingPaper.pdf
- 07aaos.orghttps://www.aaos.org/quality/resident-guide-to-coding-and-practice-management/coding-reimbursement-for-residents/
Mira Scribe
Mira's AI scribe captures the fracture pattern (all three malleoli named), the closed approach with no incision, the specific manipulation technique used, pre- and post-reduction X-ray findings, and the immobilization method applied. This prevents the most common audit flag — an operative note that doesn't explicitly distinguish trimalleolar from bimalleolar involvement or fails to document that manipulation occurred, both of which trigger downcoding or denial.
See how Mira captures CPT 27818 documentation