Orthopedic Coding Alert

Question: How do you code for the following procedure? “Over the point of tenderness, 2 to 2.5 cm incision was made over the medial aspect of the Achilles tendon and the paratenon was identified and stripped over the posterior 2/3 of the Achilles tendon. The nodular area measured around 1.5 cm in length. A pattern of TOPAZ perforation 3 rows wide and approximately 4 to 5 puncture sites longitudinally was then made at intervals of approximately 5 mm. The wound was closed with 3-0 nylon vertical mattress suture.”

California Subscriber

Answer: Without knowing the definitive diagnosis, you won’t know the definitive diagnosis. However, some possibilities are code 27630 (Excision of lesion of tendon sheath or capsule [eg, cyst or ganglion], leg and/ or ankle) along with ICD-10 code M76.60 (Achilles tendinitis, unspecified leg) because your report did not specify which leg. Read the description to confirm if tenotomy was done, you may then report 27605 (Tenotomy, percutaneous, Achilles tendon [separate procedure]; local anesthesia) if one was done in local anesthesia and 27606 (Tenotomy, percutaneous, Achilles tendon [separate procedure]; general anesthesia) if it was done under general anesthesia. You may report 27680 (Tenolysis, flexor or extensor tendon, leg and/or ankle; single, each tendon) if a tenolysis was done.