Podiatry Coding & Billing Alert

If you see your share of athletes, you probably treat a fair number of sprained ankle ligaments. Pay close attention to the number of incisions and ligaments detailed in the report, and whether the podiatrist also found a fracture, to ensure you arrive at the correct ligament repair code -- and the reimbursement you deserve.

To avoid missing out on ethical reimbursement for ligament repair, check how many ligaments and incisions the operation involves. These numbers will help you capture all allowed ligament repair charges without overcoding.

Don't overlook: There are two collateral ligament groups on each ankle, the medial and lateral, notes Richard D. Odom, DPM, ABPS, CPC, a podiatrist in Spanish Fort, Ala. Code 27695 (Repair, primary, disrupted ligament, ankle; collateral) refers to repairing a new injury of either the medial or lateral structures, not both. Realize one ligament means one code regardless of number of incisions. If the podiatrist repairs a single ligament in connection with a new injury, report 27695 once. If the podiatrist makes multiple incisions to repair a single ligament, you would still report 27695 once, says John F. Bishop, PA-C, CPC, CGSC, CPRC, president of Bishop & Associates, a coding, compliance, and reimbursement consulting service in Tampa, Fla.Include the appropriate location modifier, RT (Right side) or LT (Left side) for the repair.

When multiple ligaments within the lateral (or the medial) structures need repairing, report 27695 with a modifier. If the podiatrist repairs multiple ligaments in one of the collateral complexes (such as repairing both the anterior talofibular and calcaneofibular ligaments in the lateral structure), report 27695 per each ligament on separate lines, instructs Kristine Newton, CPC, billing coordinator at Sarasota Orthopedic Associates in Florida.

Tip: In order to report 27695 more than once per foot, the podiatrist would need to repair more than one ligament of the lateral or medial structures and make a separate incision for each repair, says Bishop.

You also need to append modifier 59 (Distinct procedural service) when reporting 27695 for two or more repairs, says Newton. The surgeon should specify which ligament(s) he is repairing in the operative report. Be sure documentation supports the different sites before using 59.

Don't forget the diagnosis code; for instance, 718.87 (Other joint derangement not elsewhere classified, ankle and foot) may apply when reporting multiple units of 27695.

When the podiatrist repairs ligaments of both the medial collateral and lateral collateral complexes on the same side, says Bishop, the correct code is:

• 27696 -- Repair, primary, disrupted ligament, ankle; both collateral ligaments

Example: If the surgeon treats the lateral anterior talofibular and the medial tibionavicular ligaments on the same ankle, for instance, and you mistakenly report one line of 27695 instead of 27696, you lose $80.83. Code 27696 has 2.24 relative value units (RVUs) more than 27695, using the 2010 Medicare Physician Fee Schedule. Code 27696 has 15.04 RVUs, while 27695 has 12.8.

Report 27696 only once, regardless of the number of ligaments repaired in the medial and lateral complexes. You may report 27696 more than once only if the podiatrist repairs ligaments from the medial and lateral complexes on both ankles, says Odom.

For repeat repairs, use 27698 (Repair, secondary, disrupted ligament, ankle, collateral [e.g., Watson-Jones procedure]). This ligament repair code has the most RVUs (17.12).

Report 27698 when the podiatrist returns for a repeat repair after the initial repair, or when the ligament needs additional treatment later on in the injury phase "after failure of conservative treatment," Bishop says.

Another way to look at it: "Primary [repair] would be for an acute problem; secondary [repair] for a chronicproblem," explains Newton.

Several diagnosis options present themselves for27695, while only one goes along with reporting of 27696.

When reporting 27695, says Newton, possible diagnosis codes may include:

717.81 -- Old disruption of lateral collateral ligament

718.87 -- Other joint derangement not elsewhere classified, ankle and foot

824.2 -- Fracture of lateral malleolus, closed

824.4 -- Bimalleolar fracture, closed

824.9 -- Unspecified fracture of ankle, open

837.0 -- Closed dislocation of ankle

845.00 -- Sprains and strains of ankle and foot, ankle, unspecified site

845.01 -- ... deltoid (ligament), ankle

845.02 -- ... calcaneofibular (ligament)

845.03 -- ... tibiofibular (ligament), distal.

Most contractor and payers accept only 718.87 to support medical necessity for 27696.

Wondering if a fracture code, such as 27814 (Open treatment of bimalleolar ankle fracture [eg, lateral and medial malleoli, or lateral and posterior malleoli, or medial and posterior malleoli],includes internal fixation, when performed) is a good choice for certain ligament repairs? "I would be hesitant to use [27814] for repair of an ankle ligament," Newton comments.

Why: The diagnosis on the claim would be specific to the ankle ligament and, thus, the  ligament repair codes would be more appropriate. Moreover, 27814 does not mention repair of the ligament in the descriptor.

However: If the surgeon repaired a fracture and repaired a ligament, the National Correct Coding Initiative (CCI) edits allow for reporting 27814 (20.19 RVUs) together with 27695, 27696, or 27698, says Newton.

Look for: If the bimalleolar fracture still has the ligaments attached, then report only 27814, advises Bishop. However, if documentation supports a difficult repair, extra work to first fix the fracture, and then a separate repair of avulsed or torn ligaments, then you would have justification to also report one of the ligament repair codes, he says.