Size up Your Syndesmosis Surgical Coding
Question: A 22-year-old patient suffered a rupture of their distal tibiofibular ligament in their left ankle after getting tackled while playing football. The podiatrist performed an open surgery with TightRope fixation on the syndesmosis. What codes will I report for the encounter? North Dakota Subscriber Answer: Use 27829 (Open treatment of distal tibiofibular joint (syndesmosis) disruption, includes internal fixation, when performed) appended with modifier LT (Left side) to report the open surgery on the syndesmosis. Next, you’ll assign S93.432A (Sprain of tibiofibular ligament of left ankle, initial encounter) to report the distal tibiofibular ligament rupture. In the ICD-10-CM Alphabetic Index, Rupture > traumatic > ligament > ankle redirects you to Sprain > ankle. Under Sprain > ankle > tibiofibular ligament, you’ll find S93.43- (Sprain of tibiofibular ligament). Turn to the Tabular List to verify your code selection. Double-check the documentation: Avoid incorrect coding by making sure the physician’s documentation clearly details the fixation used during the surgery, the diagnosis as well as its cause and severity, and the surgical steps are described thoroughly. Mike Shaughnessy, BA, CPC, Production Editor, AAPC
