Orthopedic Coding Alert

Question: Our surgeon repaired a bimalleolar fracture and the posterior tibial tendon. The tendon was completely ruptured. What I am confused about is whether I can report the tendon repair with the fracture repair. What code should I report?

Maine Subscriber

Answer: You first need to check documentation for the pathology of the tendon rupture. You may report the pathology to imply that the tendon rupture was distinct from the fracture. From the description shared, the best choice seems to be code 27658 (Repair, flexor tendon, leg; primary, without graft, each tendon).

Note that the posterior tibial tendon is a flexor tendon. You report 27814 (Open treatment of bimalleolar ankle fracture [e.g., lateral and medial malleoli, or lateral and posterior malleoli, or medial and posterior malleoli], includes internal fixation, when performed) for the ORIF of the bimalleolar ankle fracture. You need to apply modifier 51 (Multiple procedures) to the second code, because the orthopedic surgeon performed this procedure through one of the bimalleolar ORIF incisions.