Orthopedic Coding Alert

Question: Encounter notes indicate that a patient who had ruptured their right Achilles tendon three years ago ruptured the tendon again. After a magnetic resonance imaging (MRI) with contrast materials confirmed the extent of damage to the tendon and the spontaneous rupture’s location, the surgeon opts for surgery to repair the damage. The surgeon makes an incision over the back of the ankle, in line with the Achilles tendon. They then dissect away scar tissue and expose the damaged Achilles while also removing degenerative tissue. The surgeon sutures the ruptured ends of the Achilles together using the Bucknell technique. They also reinforced the repair with synthetic grafts. The surgeon then irrigates the wound and closes the incision using staples. How should I report this encounter?

Minnesota Subscriber

Answer: This is a secondary repair to the Achilles, since you mentioned that the patient had ruptured the tendon three years earlier. On the claim, you will report:

• 27654 (Repair, secondary, Achilles tendon, with or without graft)
• 73719 (Magnetic resonance (eg, proton) imaging, lower extremity other than joint; with contrast material(s))
• Modifier RT (Right side) appended to 27654 to and 73719 to indicate laterality
• M66.871 (Spontaneous rupture of other tendons, right ankle and foot) appended to 27654 and 73719 to represent the patient’s injury.