Revenue Cycle Insider

Preparing for a range of possibilities is crucial for smart Achilles repair coding.

When a patient suffers an Achilles tendon injury, the pain is usually immediate and unyielding. However, the task of coding Achilles tendon services doesn't have to be a daunting one. We will simplify this process for you by explaining the distinctions between Achilles repair codes.

Read through the three scenarios below to sharpen your Achilles tendon repair code knowledge and improve your chances of successful claim payment.

Look at This Achilles Tendon Injection Scenario

The patient was brought to the table and laid in a prone position. Their right knee was flexed to 90 degrees, and their right Achilles tendon was identified using an ultrasound. Their skin was cleaned in the usual sterile fashion using Betadine and alcohol. Under the guidance of ultrasound, a 22-gauge needle was inserted below the Achilles tendon and after negative aspiration of blood, 10 cc of 1 percent lidocaine was injected above the fat pad and under the Achilles tendon, hydro-dissecting the two layers. Patient tolerated the procedure well and there were no complications. A bandage was applied. Patient noted immediate improvement in the pain after the injection. Achilles tendinitis, right leg (M76.61) was the diagnosis for this patient.

Answer: This will depend on the practitioner’s notes. If your podiatrist doesn’t specify that the tendon was directly injected, then you should report 20606 (Arthrocentesis, aspiration and/or injection, intermediate joint or bursa (eg, temporomandibular, acromioclavicular, wrist, elbow or ankle, olecranon bursa); with ultrasound guidance, with permanent recording and reporting) with a diagnosis of Achilles tendinitis, as you stated. However, if the tendon was directly injected, you should report 20551 (Injection(s); single tendon origin/insertion).

Coding note: According to Jennifer McNamara, CPC, CCS, CRC, CPMA, CDEO, COSC, CGSC, COPC, director of healthcare training and practice support at Healthcare Inspired LLC in Bella Vista, Arkansas, you can also report 76942 (Ultrasonic guidance for needle placement (eg, biopsy, aspiration, injection, localization device), imaging supervision and interpretation) with 20551 if you have medical documentation to justify this, but it would be far less typical than simply using code 20606.

Check Out This Questionable Diagnosis Scenario

How should you document an Achilles rupture diagnosis that our provider describes as “probable,” “suspected,” “questionable,” “ruled out,” or words to that effect?

Answer: The answer to this question depends on the facility for which you are coding. For “inpatient admissions to short-term, acute, long-term care, and psychiatric hospitals,” per ICD-10-CM guideline II.H, “if the diagnosis documented at the time of discharge is qualified as ‘probable,’ ‘suspected,’ ‘likely,’ ‘questionable,’ ‘possible,’ ‘still to be ruled out,’ ‘compatible with,’ ‘consistent with,’ or other similar terms indicating uncertainty, code the condition as if it existed or was established.”

Guidelines for outpatient encounters, however, are different. Per guideline IV.H, you should not “code diagnoses documented as ‘probable,’ ‘suspected,’ ‘questionable,’ ‘rule out,’ ‘compatible with,’ ‘consistent with,’ or ‘working diagnosis,’ or other similar terms indicating uncertainty.” Instead, the guideline tells you to “code the condition(s) to the highest degree of certainty for that encounter/visit, such as symptoms, signs, abnormal test results, or other reason for the visit.”

In the outpatient setting, then, that means coding the findings or symptoms you see in the note, but not submitting a code for a definitive diagnosis. For example, suppose your podiatrist sees a patient who reports with pain and swelling in her left heel. Your podiatrist suspects a ruptured left Achilles tendon and orders an ultrasound to confirm or rule out the rupture.

In this instance, until the podiatrist can review the ultrasound results to determine whether the tendon is indeed ruptured, you should not use S86.012A (Strain of left Achilles tendon, initial encounter). Instead, for the initial encounter, you should look through the podiatrist’s notes and locate the signs or symptoms the patient reported at the initial encounter. For this encounter, that could mean coding M25.572 (Pain in left ankle and joints of left foot) or possibly R22.42 (Localized swelling, mass and lump, left lower limb) depending on provider documentation.

Here’s a Ruptured Achilles Tendon Scenario

The patient came in experiencing extreme pain and showing significant swelling of their left heel. The patient was trail hiking and landed incorrectly on their foot when they slipped on the side of a hill. They reported hearing a popping sound when the injury occurred. The podiatrist conducted an examination and used magnetic resonance imaging (MRI) to identify a ruptured Achilles tendon in the patient. Given that the injury was identified as an acute tear of the Achilles, the decision was made to proceed with a primary repair without the use of a graft.

Answer: You should report 27650 (Repair, primary, open or percutaneous, ruptured Achilles tendon) with the LT (Left side) modifier appended on your claim. For the ICD-10-CM code, you would report S86.012A (Strain of left Achilles tendon, initial encounter). For more claim detail, you should also report the external cause code Y93.01 (Activity, walking, marching and hiking on level or elevated terrain).

Don’t miss: For this type of scenario, the patient usually has an acute Achilles tear, and they will present with sudden lower extremity pain, normally around the ankle or calf. Often, the patient will sustain this type of Achilles tear while hiking, jogging, playing a sport or other high-impact activity. However, sometimes the tendon can rupture spontaneously with no specific injury to point to.

Documentation tip: When your podiatrist performs a primary Achilles repair, you must first check the medical documentation to see if they did or did not use a graft, because this information will impact your CPT^® code choice. If your podiatrist performs a primary Achilles repair without a graft, you should report 27650. According to the 27650 code descriptor, you can report this code if the repair is either open or percutaneous.

According to McNamara, “Documentation would be expected to show that diagnostic imaging confirmed the diagnosis of the rupture. The approach, as well as the techniques used, such as Krakow, Bunnell, or modified Kessler suture techniques — which aim to securely reattach the tendon ends while minimizing tension and ensuring proper alignment for optimal healing — would also need to be noted.”

Also, when you report 27650 on your claim, you must make sure that your podiatrist’s documentation specifies whether the tear was due to an injury or to a spontaneous rupture.

If your practitioner did use a graft, you would report code 27652 (Repair, primary, open or percutaneous, ruptured Achilles tendon; with graft (includes obtaining graft)) instead.

Lindsey Bush, BA, MA, CPC, Development Editor, AAPC