Podiatry Coding & Billing Alert

Question: The podiatrist performed a level-three evaluation and management (E/M) service for an established patient who has a spontaneous rupture of the extensor tendons of her right ankle and foot. Which ICD-10 code should I report for this condition?

Florida Subscriber

Answer: You should report M66.271 (Spontaneous rupture of extensor tendons, right ankle and foot) for the diagnosis code and 99213 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: An expanded problem focused history; An expanded problem focused examination; Medical decision making of low complexity …) for the E/M code.

Spontaneous ankle and foot ruptures defined: Spontaneous tendon ruptures in the ankle and foot can occur in the absence of injury, and they might be caused by something like inherent weakness. This weakness might be due to medication, advanced age, renal transplantation, etc. Also, diseases like hypercholesterolemia, gout, or rheumatoid arthritis could be the cause of a spontaneous foot and ankle rupture.

According to the Foot and Ankle Online Journal, “spontaneous tendon rupture is directly correlated with a combination of mild trauma and chronic degeneration of a tendon. Other contributing factors are systemic diseases, biomechanical abnormalities, fluoroquinolone use, and steroid usage.”