A patient has a longitudianl split tear of the peroneus brevis tendon of the left lower extremity. The physician performed a debridement and primary repair of peroneus brevis tendon. The physician is looking at code 27664 and I'm thinking 28208. The tear is on the outside of the patient's foot not quite up to the ankle. Here's the main part of the sx notes:
A hockey stick incision was made posterior & inferior to the level of the fibula & tibial malleolus distally. The incision was deepened through skin and subcutaneous tissue with care being taken to identify and retract vital neurovascular structures. The tendon sheath was identified & incised at the level of the peroneal tendons. The tendon sheath was completely opened within the the full extent of the surgical wound. The peroneus longus tendon was identified & evaluated & noted to have no direct injury or split tear presen. The peroneus brevis tendon was identified & noted to have a 6 cm longitudinal split tear with additional areas of fragmentation. All these areas were debrided and freed, and these sections of nonviable tendon were sent from the operating table for specimen and pathological evaluation. At this time the tendon was reapproximated and tubularized using a 2-0 Ethibond stitch in a running locking suture technique....
The rest of the report is closing the sx area.
A hockey stick incision was made posterior & inferior to the level of the fibula & tibial malleolus distally. The incision was deepened through skin and subcutaneous tissue with care being taken to identify and retract vital neurovascular structures. The tendon sheath was identified & incised at the level of the peroneal tendons. The tendon sheath was completely opened within the the full extent of the surgical wound. The peroneus longus tendon was identified & evaluated & noted to have no direct injury or split tear presen. The peroneus brevis tendon was identified & noted to have a 6 cm longitudinal split tear with additional areas of fragmentation. All these areas were debrided and freed, and these sections of nonviable tendon were sent from the operating table for specimen and pathological evaluation. At this time the tendon was reapproximated and tubularized using a 2-0 Ethibond stitch in a running locking suture technique....
The rest of the report is closing the sx area.