Orthopedic Coding Alert

Journey to this surgery will likely begin with E/M, imaging.

When a patient reports to the orthopedist complaining of foot pain, the surgeon could end up performing a foot tendon repair or tenolysis to remedy the condition.

As there are different code sets for both procedures, coders need to know how the characteristics of both, so they don’t end up miscoding the claim.

Read on for advice on coding foot tendon repair and tenolysis.

E/M Often Leads to X-Ray, MRI

Often, the orthopedist’s initial encounter with a tendon repair/tenolysis patient would start with an office/outpatient evaluation and management (E/M) service. “Initial determination will be based upon physical exam and patient complaints, tenderness along the course of the tendon or the attachment of the tendon,” explains Ruby O’Brochta-Woodward BSN, CPC, CDEO, CPMA, CPCO, CPB, COSC, CSFAC, CPC-I.

The patient might complain that the tendon is catching or slipping, or there is pain with certain motions that are tendon-dependent, Woodward explains. If this E/M is office/ outpatient, report it with a code from the 99202 (Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and straightforward medical decision making. When using time for code selection, 15-29 minutes of total time is spent on the date of the encounter.) through 99215 (Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and high level of medical decision making. When using time for code selection, 40-54 minutes of total time is spent on the date of the encounter.) code set.

If the physician needs further study on the patient’s injury, the E/M “would be followed by X-rays to rule out any fractures. Also, an MRI [magnetic resonance imaging] is usually ordered to better view the soft tissues, tendons and ligaments,” according to Wayne Conway, CPC, CGSC, COSC, physician coder II at WakeMed Physicians Practice in Raleigh, N.C.

For the X-rays you’d likely report a code such as 73620 (Radiologic examination, foot; 2 views) or 73630 (… complete, minimum of 3 views). For the MRI, you’d likely use one of the following codes:

• 73718 (Magnetic resonance (eg, proton) imaging, lower extremity other than joint; without contrast material(s))
• 73719 (… with contrast material(s))
• 73720 (… without contrast material(s), followed by contrast material(s) and further sequences)
• 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)

Note: This is not a complete list of the tests/services your surgeon might employ to identify foot tendon repair/tenolysis candidates. Always code to the notes, and check your payer contract if you have questions regarding testing and services surrounding these surgeries.

Know What Separates Tendon Repair, Tenolysis

Once the surgeon decides operating is necessary, they’ll perform either a foot tendon repair or a tenolysis. Be prepared to differentiate between the two, because it will affect code choice.

“Many times, a tendon repair is performed for a traumatic rupture, avulsion, or laceration of a tendon,” Conway says. The tear could occur during an automobile accident, a fall from a high place, or even a lawnmower accident. Also, “patients could have an old tendon tear injury/chronic condition that needs to be repaired as well. Tendon repairs are not always for an acute injury,” Conway clarifies.

“With a tendon repair the tendon is either completely or partially torn. How they repair it will be dependent on where it is torn and how good the rest of the tendon is,” explains Woodward.

For a foot tendon repair, choose from the following codes, depending on encounter specifics:

• 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))

Tenolysis surgery is far less involved, expert coders report.

“A tendon tenolysis might be performed for an old injury that has now healed but has scar tissue or tenosynovitis built up around the tendon causing pain and stiffness,” Conway explains. “Sometimes an old injury could have a tendon tear but the tear is not large enough that it warrants a repair. A tenolysis would be appropriate in these instances.”

For tenolysis, choose from the following codes, depending on encounter specifics:

• 28220 (Tenolysis, flexor, foot; single tendon)
• 28222 (… multiple tendons)
• 28225 (Tenolysis, extensor, foot; single tendon)
• 28226 (… multiple tendons)

Remember: “One thing to keep in mind is that both range of repair and tenolysis codes are separated according to extensor and flexor tendons, so keep that in mind when choosing the appropriate codes,” says Conway.

These Diagnoses Often Tagged to Tendon Repair/Tenolysis Claims

There are certain diagnoses that you could see during a foot tendon repair/tenolysis encounter form. Though this is not a definitive list, here are a few diagnosis codes for conditions that lead to tendon repair or tenolysis:

Tendon Repair Dx Examples

• M66.27- (Spontaneous rupture of extensor tendons, ankle and foot)
• M66.37- (Spontaneous rupture of flexor tendons, ankle and foot)
• S96.01 - (Strain of muscle and tendon of long flexor muscle of toe at ankle and foot level)
• S96.02- (Laceration of muscle and tendon of long flexor muscle of toe at ankle and foot level)
• S96.11- (Strain of muscle and tendon of long extensor muscle of toe at ankle and foot level)
• S96.12- (Laceration of muscle and tendon of long extensor muscle of toe at ankle and foot level)
• S86.31- (Strain of muscle(s) and tendon(s) of peroneal muscle group at lower leg level)
• S86.32- (Laceration of muscle(s) and tendon(s) of peroneal muscle group at lower leg level)

Tenolysis DX examples

• M65.87- (Other synovitis and tenosynovitis, ankle and foot)
• M76.7- (Peroneal tendinitis).