EM Coding Alert

Tip: Ensure documentation explains X-Ray, MRI usage.

A patient who ruptures their Achilles tendon may show up in an emergency department (ED) to receive care — and a diagnosis.

While the ED physician probably wouldn’t be involved in a surgery to repair the injury, they may provide a diagnosis before sending the patient to another provider. The diagnosis process may involve a Thompson test.

Look for Thompson Test as Part of E/M Service

When a patient has a suspected ruptured Achilles, they will typically report pain in the back of their ankle/calf area, often from a traumatic injury such as a fall. “There could also be mild swelling and tenderness in the area. Sometimes, a palpable defect can be felt in the area of the Achilles tendon,” explains Wayne Conway, CPC, CGSC, COSC, physician coder II at WakeMed Physicians Practice in Raleigh, North Carolina.

Conway adds, “If the tendon is torn there will be a noticeable loss of flexion movement with the foot and ankle.”

The most common way for physicians to check for ruptures is to perform a Thompson test, which would occur during an ED evaluation and management (E/M) service, Conway says.

During a Thompson test, the provider squeezes the calf to test the Achilles and surrounding areas to check for any defects and injuries. While the Thompson test is not separately reportable, it contributes to the overall MDM. You would roll the work into the overall E/M service when choosing a code from the 99281 (Emergency department visit for the evaluation and management of a patient that may not require the presence of a physician or other qualified health care professional) through 99285 (Emergency department visit for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and high level of medical decision making) set.

Understand X-Ray, MRI Involvement

If there is strong suspicion that there is a defect in the Achilles area, the provider will likely perform an imaging study to confirm any injuries. Often this is a magnetic resonance imaging (MRI), says Lynn M. Anderanin, CPC, CPMA, CPPM, CPC-I, COSC, senior director of coding education at Healthcare Information Services in Park Ridge, Illinois.

When the provider performs an MRI to check for Achilles tendon trauma, you’ll report one of the following codes for the facility:

• 73721 (Magnetic resonance (eg, proton) imaging, any joint of lower extremity; without contrast material)
• 73722 (… with contrast material(s))
• 73723 (… without contrast material(s), followed by contrast material(s) and further sequences)

The provider could also opt for an X-ray to check the area for fracture or dislocation, Conway says. You’d report these X-rays with 73590 (Radiologic examination; tibia and fibula, 2 views).’

Remember: As the facility will be coding for the MRI or X-ray, you won’t include codes for either service on your claim. You would, however, consider the work that informs the decision to get the MRI/X-ray as part of the overall E/M.

ICD-10-CM coding: For injuries of Achilles tendon diagnoses, you’ll head to the S86.0- code set. There are codes in the set for unspecified injury of Achilles, as well as strain and laceration. If the provider indicates that the Achilles is ruptured, however, you’ll choose one of the following codes:

• S86.091A (Other specified injury of right Achilles tendon, initial encounter)
• S86.092A (Other specified injury of left Achilles tendon, initial encounter)
• S86.099A (Other specified injury of unspecified Achilles tendon, initial encounter)

Consider Clinical Scenario

For an illustration of how these Achilles rupture encounters might play out in real life, here’s a detailed clinical example from Conway:

Example: An elderly patient reports to the ED after stepping off a curb and feeling a pop in the back of their left leg. The patient complains of pain in the Achilles/gastrocnemius tendon area. The provider observed mild swelling and tenderness and performed a Thompson test. The test revealed a palpable defect and a loss of flexion movement. An X-ray was ordered to rule out a fracture or dislocation. An MRI was then performed, which confirmed a left Achilles rupture. The provider placed the patient in a walking boot and helped them with follow-up appointments with an orthopedic surgeon to have the tendon repaired. Notes indicate that the provider performed high medical decision making (MDM) during the E/M portion of the service.

For this encounter, you’d report:

• 99285 (Emergency department visit for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and high level of medical decision making) for the E/M service.
• S86.092A appended to 99283, 73590, and 73722 to indicate the patient’s ruptured Achilles.