Orthopedic Coding Alert

Question: Our podiatrist performed an ankle gutter debridement along with peroneal and posterior tibial tendon exploration on a patient with primary osteoarthritis in the right ankle. The podiatrist’s notes stated that there was severe bony impingement, which they extensively debrided both on the talus and medial malleolar side, and that they conducted debridement from anterior to posterior including the entire gutter to the point where there was no evidence of any further bony impingement.

What is the correct way to go about coding this?

AAPC Forum Participant

Answer: For the procedure, your best bet would be to use 27620 (Arthrotomy, ankle, with joint exploration, with or without biopsy, with or without removal of loose or foreign body). The procedure involves the provider making an incision in the joint between two bones, then exploring the area and biopsying and/or removing any material, such as bone or a foreign body, if appropriate.

Don’t forget: To justify medical necessity for the procedure, you’ll use M19.071 (Primary osteoarthritis, right ankle and foot).