Podiatry Coding & Billing Alert

Question: In our office we see a lot of cases of PTTD and plantar fasciitis. What are their codes and symptoms?

Maryland Subscriber

Answer: Posterior Tibial Tendon Dysfunction (PTTD), also known as posterior tibial tendonitis is one of the leading causes of acquired flatfoot in adults caused when the posterior tibial tendon becomes inflamed, stretched out or torn.

An abrupt onset is typically linked to some form of trauma, whether it be simple (stepping down off a curb or ladder) or severe (falling from a height or automobile accident). PTTD is seldom seen in children and increases in frequency with age. In the physician’s notes, you may find one or many of the following symptoms:

• Loss of medial arch height
• Edema (swelling) of the medial ankle
• Loss of the ability to resist force to abduct or push the foot out from the midline of the body
• Pain on the medial ankle with weight bearing
• Inability to raise up on the toes without pain
• Too many toes sign

A podiatrist upon suspicion of PTTD will employ a common test called the ‘too many toes sign.’ The ‘too many toes sign’ is a test used to measure abduction (deviation away from the midline of the body) of the forefoot. With damage to the posterior tibial tendon, the forefoot will abduct or move out in relationship to the rest of the foot. In cases of PTTD, when the foot is viewed from behind, the toes appear as ‘too many’ on the outside of the foot due to abduction of the forefoot. The physician will also diagnose this condition using a physical exam and x-ray. PTTD can be reported with code M76.821 (Posterior tibial tendinitis, right leg), M76.822 (Posterior tibial tendinitis, left leg), or M76.829 (Posterior tibial tendinitis, unspecified leg). The physicians will usually attempt to repair this condition by prescribing rest, nonsteroidal anti-inflammatory drugs (NSAIDs), and possibly casting or bracing. In some cases, surgery such as tenosynovectomy (27680, Tenolysis, flexor or extensor tendon, leg and/or ankle; single, each tendon), tendon transfer (27691, Transfer or transplant of single tendon [with muscle redirection or rerouting]; deep [e.g., anterior tibial or posterior tibial through interosseous space, flexor digitorum longus, flexor hallucis longus, or peroneal tendon to midfoot or hindfoot]) or triple arthrodesis (28715, Arthrodesis; triple) may be required.

Plantar fasciitis: This condition is characterized by heel pain caused by inflammation of the plantar fascia. Physicians describe a variety of sources of this condition, including athletics without appropriate warm-up, stress on the arch, ill-fitting shoes, and sports-related stress on the heel.

The diagnostic code for plantar fasciitis is M72.2 (Plantar fascial fibromatosis). Physicians can usually diagnose plantar fasciitis during a physical exam. Treatment includes NSAIDs to relieve pain and inflammation; rest; stretching exercises, shoe inserts, night splints, and, if other therapy is ineffective, corticosteroid injections.

In some cases, physicians have success with extracorporeal shock wave therapy (ESWT, 28890, Extracorporeal shock wave, high energy, performed by a physician or other qualified health care professional, requiring anesthesia other than local, including ultrasound guidance, involving the plantar fascia) for this condition. If these treatments fail, the podiatrist may feel that the patient requires surgery, such as an endoscopic plantar fascia release (29893, Endoscopic plantar fasciotomy) or an open plantar fascia release such as 28060 (Fasciectomy, plantar fascia; partial [separate procedure]). The open procedure is still much more common.