Orthopedic Coding Alert

Tenolysis/tendon surgeries can test your coding ability.

When orthopedic surgeons perform tendon surgery on a patient’s feet, you’ll often find yourself choosing a code from the tendon repair/tenolysis set.

Which code you’ll choose is often vexing, however. There are a lot of variables — and codes — that are in play when a patient needs foot tendon repair/tenolysis.

The challenge: There are two coding scenarios below. Each of them will feature a surgical code (or codes) from the following list:

• 28200 (Repair, tendon, flexor, foot; primary or secondary, without free graft, each tendon)
• 28202 (… secondary with free graft, each tendon (includes obtaining graft))
• 28208 (… primary or secondary, each tendon)
• 28210 (… secondary with free graft, each tendon (includes obtaining graft))
• 28220 (Tenolysis, flexor, foot; single tendon)
• 28222 (… multiple tendons)
• 28225 (Tenolysis, extensor, foot; single tendon)
• 28226 (… multiple tendons)

There will also be opportunities to code other procedures and services in these scenarios, as well as ICD-10 codes to assign in order to paint a picture of the patient’s condition. See how your coding skills stack up by trying to completely code the scenarios below:

(Scenarios and coding expertise courtesy of Wayne Conway, CPC, CGSC, COSC, physician coder II at WakeMed Physicians Practice in Raleigh, N.C.)

SCENARIO 1

Encounter notes: Est. Px fell through the attic while putting boxes away. Fell approximately 10 feet. Landed on both feet then fell backward. Px is ambulating and walking on their feet. Said they have some pain in bilateral heels. Gross examination did not reveal anything significant. X-rays and CTs ordered of both feet

Final Dx: Right displaced calcaneal body fracture and flexor tendon tear right foot; left nondisplaced calcaneal body fracture

Surgery & E/M: Well molded short leg splint applied on the right side, and well molded short leg plantar flexed applied on the left side. E/M surgeon performed when deciding for surgery lasted 37 minutes.

SCENARIO 1 CODING

CPT^® Coding

On the claim, you’d report:

• 28415 (Open treatment of calcaneal fracture, includes internal fixation, when performed)
• 28200
• Modifier RT (Right side) appended to 28415 and 28200
• 28400 (Closed treatment of calcaneal fracture; without manipulation)
• Modifier LT (Left side) appended to 28400
• 99214 (Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making. When using time for code selection, 30-39 minutes of total time is spent on the date of the encounter.)
• Modifier 57 (Decision for surgery) appended to 99214

ICD-10 Coding

On the claim, you’d report the following ICD-10/CPT^® code combinations:

• S96.011A (Strain of muscle and tendon of long flexor muscle of toe at ankle and foot level, right foot, initial encounter) appended to 28200 and 99214
• S92.011A (Displaced fracture of body of right calcaneus, initial encounter for closed fracture) appended to 28415 and 99214
• S92.015A (Nondisplaced fracture of body of left calcaneus, initial encounter for closed fracture) appended to 28400 and 99214
• W13.3XXA (Fall through floor, initial encounter) appended to 28415, 28200, 28400, and 99214

SCENARIO 2

Encounter notes: New patient reports right ankle pain and ankle instability/inflammation and flexor tendon tendonitis. Patient is a collegiate soccer player that presents with right ankle pain, with chronic multiple ankle sprains, at least 6 over the past 4 years or so. They have recovered quickly from all of them with some PT, except most recent one which occurred about 6 weeks ago. They have had no significant improvement over the course of the past 5 to 6 weeks despite PT. They are here for second opinion. They have an MRI. Pain is mainly posterior lateral in nature.

Final Dx: Instability, right ankle; tenosynovitis, right ankle and foot

Surgery & E/M: Tenolysis single tendon right foot.

Notes indicate that a 43-minute E/M resulted in the decision to perform surgery on the patient.

SCENARIO 2 CODING

CPT^® coding:

• 28220
• Modifier RT (Right side) appended to 28220
• 99203 (Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and low level of medical decision making. When using time for code selection, 30-44 minutes of total time is spent on the date of the encounter.)
• Modifier 57 appended to 99203

ICD-10 coding:

• M25.371 (Other instability, right ankle) and M65.871 (Other synovitis and tenosynovitis, right ankle and foot) appended to 28220 and 99203.