Bimalleolar fracture, closed

This code represents a closed fracture affecting both the medial and lateral malleoli of the ankle. This type of injury typically results from rotational forces and involves disruption of the ankle mortise without an open wound exposing the bone.

Apply this code when documentation clearly states a "bimalleolar fracture" that is explicitly described as "closed." This is commonly seen in emergency department visits or initial orthopedic consultations following an ankle injury. Supporting documentation includes imaging reports (X-rays) confirming the fracture pattern and physician notes detailing the absence of an open wound.

• Ensure the documentation specifies "closed" to differentiate from open fractures (which would use a different subcategory).
• Do not confuse with trimalleolar fractures, which involve an additional fracture of the posterior malleolus.
• Always review the operative report for open reduction and internal fixation (ORIF) procedures, but this diagnosis code is for the fracture itself, not the treatment.