Orthopedic Coding Alert

Here's why a graft is a major detail in any Achilles op report.

When a patient suffers a ruptured Achilles tendon, the pain is often immediate and unrelenting. If you don't know how to code Achilles repairs, that pain could extend (metaphorically) to you.

Don't let Achilles repair coding be your tragic flaw. Check out this rundown of all you need to know about these services, so you stay standing despite any coding challenges for these repairs.

Make Graft Decision on 27650, 27652

When your surgeon performs a primary Achilles repair without a graft, you'll report 27650 (Repair, primary, open or percutaneous, ruptured Achilles tendon), confirms Chelle Johnson, CPMA, CPC, CPCO, CPPM, CEMC, AAPC Fellow, staff services coordinator/billing/credentialing/auditing/coding at County of Stanislaus Health Services Agency in Modesto, California.

Consider this explanation of a typical 27650 scenario from Denise Paige, CPC, COSC, an orthopedic coder with Bright Health Physicians in Whittier, California:

"For 27650, which usually represents an acute [Achilles] tear, the patient would present with sudden lower extremity pain, usually around the ankle or calf," Paige says. Patients often describe the injury as "like being struck from behind" in the area of the injury, Paige continues. "This injury often occurs while playing sports or other high-impact activities. Sometimes the tendon ruptures spontaneously with no specific injury."

For 27650 claims, "the diagnosis should indicate laterality, initial or subsequent care, along with the use of the LT (Left side) or RT (Right side) modifier on the CPT^® code," Paige says. Also, your notes should include any indications that it's due to an injury or a spontaneous rupture, if available.

You'd code primary Achilles surgeries that employ some sort of graft with 27652 (... with graft (includes obtaining graft)). The provider will typically perform 27652 service for patients with a more complicated Achilles rupture, explains Paige.

Indicators: Very often, the notes make it clear that the surgeon used a graft during the Achilles repair. "There are a few different types of grafts that could be used," explains Johnson. Often, encounter notes for Achilles repair contain documentation "referencing various 'flaps' that will be sutured or woven to the ruptured site," Johnson says. If you see notes indicating flaps sutured or woven to the injured area, it's pretty likely the surgeon performed a graft.

Symptoms Include Heel Pain, Movement Issues

According to Johnson, the most common symptoms of an Achilles rupture include "pain and swelling at or near the heel. Any stretching of the site will be painful, such as bending forward, or pushing off; going on tip toes should be impossible or cause extreme pain," she explains. Also, some patients will describe a "popping" sound at the time of the injury and immediate sharp pain.

Quick hit: Your provider will typically discover the Achilles rupture during an evaluation and management (E/M) service and/or via X-rays or a magnetic resonance imaging (MRI). Depending on the situation, you might be able to code for these services. it's not a slam dunk, however, so be sure to check with the performing provider to see if there are any other services you should code with the Achilles repair.

Keep Secondary Repair in Back of Your Mind

When you're perusing that Achilles repair operative report, make sure you're not overlooking the possibility that this is a secondary Achilles repair. When the surgeon performs a secondary Achilles repair, you'd code the service with 27654 (Repair, secondary, Achilles tendon, with or without graft).

The surgeon would likely perform a secondary repair "for an old tear or a re-tear of a previous repair with significant retraction or scarring of the tendon. The indications should be clearly stated in the op note along with the use of the graft," Paige says.