Podiatry Coding & Billing Alert

Keep watertight documentation at hand before reporting secondary repairs. 

You are all too aware of sprained ankle ligament coding if your practice receives a large number of athletes. However, are you paying close attention to terms such as primary and secondary procedures? Are you counting the number of incisions and ligaments detailed in the report? Do you know whether the podiatrist also found a fracture? Here’s how to decode this information and master the ins and outs of ligament repair codes.

Review This Background Info 

Ankle stability is maintained due to two collateral ligament groups either side of the ankle, the medial and lateral. The lateral ligament, on the outside of the ankle, and is made up of three bands connecting the fibula (the prominent bone on the outside of the ankle) and the talus (ankle bone) and calcaneus (heel bone). If the ankle is twisted, the ligaments can become stretched or torn. This is known as a sprained ankle.

Latch On to 27695 for Primary Ligament Repair

Before coding the ligament repair, make sure to go through the op notes to capture the exact number of ligaments and incisions the podiatrist operated upon. You don’t want to overshoot these numbers in your claim and face a possible audit. 

If the physician makes a fresh repair on any one of the ligament structures — medial or lateral — it is known as a primary repair. In such a case, you should report code 27695 (Repair, primary, disrupted ligament, ankle; collateral).

Caution: Report 27695 only once irrespective of the number of the incisions the physician makes to repair the same ligament. If the podiatrist makes multiple incisions to repair a single ligament, you would still report 27695 once. Don’t forget to pinpoint the left or right foot by using the appropriate location modifier, RT (Right side) or LT (Left side), for the repair.

In some cases, your podiatrist may also have to repair multiple ligaments within the lateral (or the medial) structures. Here, you can report multiple units of 27695 for each ligament repaired. However, you need to append modifier 59 (Distinct procedural service) or the new EPSU modifier when reporting 27695 for two or more repairs. The op notes should specify which ligament(s) were repaired in the procedure. Be sure documentation supports the different sites before using 59. 

For example, if the podiatrist repairs multiple ligaments in one of the collateral complexes, such as both the anterior talofibular and calcaneofibular ligaments in the lateral structure, and he makes separate incisions for both ligaments, you will report

• 27695
• 27695 -59.

Score More for Dual Collateral Repair 

You can use 27695 only for a single sided ligament repair of a single ankle. However, if you have a case of a repair of ligaments on both the medial collateral and lateral collateral complexes of a single ankle, you should go to code 27696 (Repair, primary, disrupted ligament, ankle; both collateral ligaments).

Money matters: “Look out for terms such as ‘repair of the lateral anterior talofibular and the medial tibionavicular ligaments’ of the ankle in the op notes to avoid missing out on coding a dual repair,” says Arnold Beresh, DPM, CPC, of Peninsula Foot and Ankle Specialists PLC in Hampton, Va. If you do, you stand to lose $76.51, because code 27696 pays $566.35 (15.84 relative value units [RVUs] multiplied by 2015 conversion factor of 35.7547), whereas 27695 pays $489.84 (13.74 RVUs × 35.7547).

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.

Chronic/Repeat Repair Calls for Secondary Code

Quite usually, as in the case of athletes or sportspersons, the podiatrist has to deal with repair of chronic ligamentous problems with frequent and recurrent ankle sprains. In such cases, in order to restore function and relieve pain the provider has to perform a secondary repair of the disrupted collateral ligament by mobilizing other tendons to replace the collateral ligament. Therefore, you should opt for 27698 (Repair, secondary, disrupted ligament, ankle, collateral [e.g., Watson-Jones procedure]) if the op notes indicate a secondary repair or a repeat repair on a previously treated ankle.

However, payers will accept 27698 only when there is sufficient documentary evidence to demonstrate that there was a failure of conservative treatment. There needs to be documented evidence that the podiatrist had to intervene for a repeat repair after the initial repair or that the ligament needed additional treatment later on in the injury phase.

Correct Diagnosis Code Completes the Picture

Your claim will never be complete without proper diagnostic codes appended to the procedure. You have a choice from the following for primary repair (27695):

• 717.81 -- Old disruption of lateral collateral ligament
  
• 718.87 -- Other joint derangement not elsewhere classified, ankle and foot
  
• 824.2-824.9 -- Fracture of ankle
  
• 837.0 -- Closed dislocation of ankle
  
• 845.00-845.03 -- Sprains and strains of ankle and foot.
  

However, only one ICD-9 code is acceptable for reporting of 27696 and a majority of payers recognize only 718.87 to support medical necessity. You will also need to append 718.87 when justifying multiple units of 27695.

ICD-10: Under ICD-10, you will look at M24.87- family for the accepted diagnostic codes, especially M24.873 (Other specific joint derangements of unspecified ankle, not elsewhere classified) or M24.876 (Other specific joint derangements of unspecified foot, not elsewhere classified).

Special Situations May Justify Friendly Fracture Codes 

Sometimes, you may be led to believe that a fracture code such as 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) may also be used for certain ligament repairs. However, that would be a certain route to heartburn as the diagnosis on the claim would be specific to the ankle ligament and you would be caught on the wrong foot with the fracture codes. Moreover, 27814 does not mention repair of the ligament in the descriptor.

Exception: That does not mean that you are forever barred from using the code. If the repair procedure involved both repair of a fracture and a ligament, then you can safely report 27814 (worth $795.90) together with 27695, 27696, or 27698. For example, if the bimalleolar fracture still has the ligaments attached, then you can report only 27814. However, if documentation supports a difficult repair, extra work to initially 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.