Podiatry Coding & Billing Alert

Question: I have a rough op note that describes an incision behind the ankle to relieve pressure on the patient's posterior tibial nerve. How should I code this procedure? And for future reference, what kinds of diagnoses or conditions usually warrant this procedure?

California Subscriber

Answer: This procedure sounds like a tarsal tunnel release. But to be sure, ask your podiatrist if this is what it is, and if so, use 28035 (Release, tarsal tunnel [posterior tibial nerve decompression]) to report this procedure.

As far as recognizing a common diagnosis, you would most likely see patients with 355.5 (Tarsal tunnel syndrome), which ICD-9 defines as a "compressed, entrapped posterior tibial nerve" that causes "tingling, pain and numbness in the sole of the foot."

The tarsal tunnel release is a procedure a podiatrist usually does as a last resort for a patient with tarsal tunnel syndrome -- the close cousin to carpal tunnel syndrome, except in the foot.