CPC Chapter 8-Musculoskeletal System Practical Review Flashcards
CASE 1
PREOPERATIVE DIAGNOSIS: Painful L2 vertebral non-traumatic compression fracture.
POSTOPERATIVE DIAGNOSIS: Painful L2 vertebral non-traumatic compression fracture.(The postoperative diagnosis is used for coding.)
NAME OF OPERATION: L2 kyphoplasty.(This is the working procedure until the report is read.)
FINDINGS PREOPERATIVELY:
She had compression fractures at T11 and L1 for which she previously underwent kyphoplasty. She initially had very good results, but then developed back pain once again. The repeat MRI two weeks later showed that she had fresh high intensity signal changes in the body of L2 and some scalloping of the superior end plate, consistent with a compression fracture at L2.(The diagnosis is confirmed in the body of the report.) After some preoperative discussions and patience to see if she would get better, she was admitted to the hospital for L2 kyphoplasty when she did not improve. At surgery, L2 had some scalloping of the superior end plate. Most of the softness was in the back part of the vertebral body.
PROCEDURE:
The patient was taken to the operating room and placed under general endotracheal anesthesia(The type of anesthesia utilized is documented within the report. General anesthesia was used.) in a supine position. She was then placed prone on the Jackson table and her back was prepped and draped in the usual sterile fashion. Using biplane image intensifiers, the skin incision sites were marked. 0.5% Marcaine with epinephrine was injected. Initially on the left side. A Kyphon trocar was passed down to the superior lateral edge of the pedicle, through the pedicle, and into the vertebral body in the usual fashion.(This describes the approach to the defect. It is percutaneous using trocars.) The drill was placed into the vertebral body followed by the Kyphon bone tamp. In a similar fashion, the same thing was done on the other side. Balloons were inflated uneventfully. The balloons were then deflated and removed, and the cement (when it was in the doughy state) was injected into the two sides in the usual fashion.(This describes how the area is enlarged and the cement is placed in a kyphoplasty procedure.) This was done carefully and sequentially to make sure there were no cement extrusions, which, after inspection, there were none. There was a good fill to the vertebral body edges, up towards the superior end plate, and across the midline. The bone filling devices were removed, and the trocars were removed, Pressure was applied after which the skin was sutured with 4-0 nylon. Sand-Aids were applied and she was taken to recovery in stable condition.
COMPLICATIONS: There were no complications.
BLOOD LOSS: Minimal blood loss.
COUNTS: Sponge and needle counts were correct.
What are the CPT® and ICD-10-CM codes reported?
22514
M48.56XA
There is one CPT® code and one ICD-10-CM code reported. Kyphoplasty is a surgical procedure to treat vertebral compression fractures. The section of the vertebral column the procedure is performed is important for code selection; L2 is the lumbar region. In the CPT® Index, look for Kyphoplasty and make the code selection based on the vertebral location. Compression fractures are considered pathological in nature.
In the ICD-10-CM Alphabetic Index, Fracture, pathological/compression (not due to trauma) directing you to see also Collapse/vertebra. In the ICD-10-CM Alphabetic Index look for Collapse/vertebra/lumbar region. You can refer to ICD-10-CM guideline I.C.13.c. for guidance for the 7th character.
CASE 2
Operative Report
PREOPERATIVE DIAGNOSIS: Comminuted left proximal humerus fracture.
POSTOPERATIVE DIAGNOSIS: Comminuted left proximal humerus fracture. (The postoperative diagnosis is used for coding.)
OPERATIVE PROCEDURE: Open treatment of left proximal humerus.(The working procedure until the report is read.)
ANESTHESIA: General.(General anesthesia is used.)
IMPLANTS: DePuy GLOBAL® FX™, stem size 10 with a 48 x 15 humeral head.(This is an indication that a prosthesis was introduced into the joint.)
INDICATIONS: The patient is a 66-year-old female who sustained a traumatic severe comminuted proximal humerus fracture. (This is confirmation of the diagnosis. The proximal end of the humerus is the shoulder area.) The risks and benefits of the surgical procedure were discussed. She stated that she understood and desired to proceed.
DESCRIPTION OF PROCEDURE: On the day of the procedure, after obtaining informed consent, the patient was taken to the main operating room where she was prepped and draped in the usual sterile fashion in beach chair position after administering general anesthesia. Standard deltopectoral approach was used.(The approach is documented within the body of the operative report.) The cephalic vein was taken laterally with the deltoid. Dissection was carried out down to the fracture site and the fracture was identified. The fragments were mobilized and the humeral head fragments were removed. Once this was done, the stem was prepared up to a size 10.(This further explains the comminuted fracture.) A trial reduction was carried out with the DePuy trial stem and implant head.(Placement of the prosthesis is described.) This gave good range of motion with good stability. Sutures down to and through the shaft were placed in key positions for closure of the tuberosities. The shaft was prepared and cement was injected into the shaft. The implant was placed. Once the cement was hardened, the head was placed on Morse taper and then reduced. A bone graft was placed around the area where the tuberosities were being brought down.(Bone grafts are common in prosthetic placement. A matrix is provided where new bone can grow and further stabilize the prosthesis. These are not reported separately.) The tuberosities were tied down with a suture previously positioned. This gave excellent closure and coverage of the significant motion at the repair sites. The wound was thoroughly irrigated. The skin was closed with vicryl over a drain and staples in the epidermis. A sterile dressing and sling were applied. The patient was taken to recovery in stable condition. There were no immediate complications.
What are the CPT® and ICD-10-CM codes reported?
23616-LT
S42.202A
There is one CPT® code and one ICD-10-CM code reported. The procedure is an open treatment of a fracture of the proximal humerus. In the CPT® Index, look for Fracture/Humerus/Open treatment directing you to the code range 23615-23616. Read the descriptions carefully. Use a HCPCS Level II modifier to indicate the side of the body. The diagnosis is comminuted proximal humerus fracture. In the ICD-10-CM Alphabetic Index, locate Fracture, traumatic/humerus/proximal end referring you to see Fracture, humerus, upper end. At the beginning of category S42 in the ICD-10-CM Tabular List, there are notes defining a ‘closed’ and ‘open’ fracture, and how to code a fracture not indicated as closed or open. There is also a listing for the 7th character. See guideline I.C.19.a regarding Initial vs. Subsequent Encounters.
CASE 3
OPERATIVE REPORT
Preoperative Diagnosis: Plantar fasciitis, left
Postoperative Diagnosis: Same as preoperative diagnosis.(The postoperative diagnosis is used for coding.)
Procedures: Plantar fasciotomy, left heel.(This is the working procedure until the report is read.)
For informed consent, the more common risks, benefits, and alternatives to the procedure were thoroughly discussed with the patient. An appropriate consent form was signed, indicating the patient understands the procedure and its possible complications.
This 61-year-old male was brought to the operating room and placed on the surgical table in a supine position. Following anesthesia, the surgical site was prepped and draped in the normal sterile fashion. Attention was directed to the left heel where, utilizing a 61 blade, a stab incision was made, taking care to identify and retract all vital structures. The incision was deepened to the medial band insertion of the fascia. The fascia was then incised and avulsed from the calcaneus.(The description of the fasciotom is found within the body of the report.) The surgical site was flushed with saline. Next, 1 cc of Depo-Medrol was injected in the operative site. The site was dressed with a light compressive dressing. Excellent capillary refill to all of the digits was observed without excessive bleeding noted.
Hemostasis: none
Estimated Blood Loss: minimal
Injectables: Agent used for local anesthesia was 5.0 cc Marcaine 0.5% with epinephrine.
Pathology: No specimen sent.
Dressings: Applied Bacitracin ointment. Site was dressed with a light compressive dressing.
Condition: Patient tolerated the procedure and anesthesia well. Vital signs were stable. Vascular status was intact to all digits. Patient recovered in the operating room.
What are the CPT® and ICD-10-CM codes reported?
28008-LT
M72.2
There is one CPT® code and one ICD-10-CM code reported. The documented procedure is a plantar fasciotomy of the left heel. Look in the CPT® Index for Fasciotomy/Foot. Use HCPCS Level II modifier to indicate which side of the body the procedure was performed. In the ICD-10-CM Alphabetic Index, look for Fasciitis/plantar. Validate the code in the Tabular List.
CASE 4
PREOPERATIVE DIAGNOSIS: Painful hardware, left foot.
POSTOPERATIVE DIAGNOSIS: Painful hardware, left foot.(The postoperative diagnosis is used for coding.)
PROCEDURE PERFORMED: Removal of hardware, left foot.(This is the working procedure until the report is read.)
ANESTHESIA: Sedation and local
DRAIN: None.
ESTIMATED BLOOD LOSS: Minimal.
INDICATIONS FOR PROCEDURE:
The patient had his status post metatarsal fracture, treated with internal fiixation. Patient has suffered pain due to hardware for the past six months.(The diagnosis is confirmed in the body of the report.) Patient’s pain has been unresponsive to conservative treatment. We discussed the above-mentioned surgery, along with the potential risks and complications, and the patient understood and wished to proceed.
DESCRIPTION OF PROCEDURE:
With the patient supine on the operating table after the successful induction of anesthesia, the left foot was prepped and draped in the usual sterile fashion. In the area of the screw heads, 0.5% Marcaine was injected, both on the lateral side of the foot and the dorsal midfoot, administering about 5 ml in each area. Incisions through the skin were made and blunt dissection was carried deep down to the screw heads. The screws were removed with the screwdrivers. The incisions were irrigated and closed with simple 4-0 nylon sutures. A sterile compression dressing was applied. The patient was taken to the recovery room in satisfactory condition.
MATERIAL SENT TO LABORATORY: None.
COMPLICATIONS: None.
CONDITION ON DISCHARGE: Satisfactory.
DISCHARGE DIAGNOSIS: Painful hardware, left foot.
DISCHARGE PLAN:
Discharge instructions were discussed with the patient. A copy of the instructions was given to the patient and a copy retained for the medical record. The following items were discussed: diet, activity, wound care medications if applicable, when to call the physician, and follow-up care.
What are the CPT® and ICD-10-CM codes reported?
20680-LT
T84.84XA, G89.18
There is one CPT® code and two ICD-10-CM codes reported. Screws and plates are often used in surgery to fix fractures or fuse joints in the ankle. In most instances, these screws and plates do not create symptoms and remain in the bone. In some patients, hardware (implant) can become prominent or irritate a tendon or other soft tissue. Initially, this may be treated with padding over the area. However, if this is not satisfactory, patients may benefit from hardware removal once the fracture or fusion has fully healed. When choosing the CPT® code, look for Removal/Fixation Device. Read the code description(s) carefully to determine what is ‘superficial’ and ‘deep’. No informational modifier is used on this code.
The first diagnosis is for the pain due to the hardware (device or implant). This is considered a complication. In the ICD-10-CM Alphabetic Index, look for Complication/orthopedic/device or implant/pain. The second diagnosis is for post-procedural pain. Refer to ICD-10-CM guideline I.C.6.b.3.b. for guidance. In the Alphabetic Index look for Pain(s)/postoperative NOS
CASE 5
PREOPERATIVE DIAGNOSIS: Right ankle triplane fracture
POSTOPERATIVE DIAGNOSIS: Right ankle triplane fracture(The postoperative diagnosis is used for coding.)
PROCEDURE: Open reduction and internal fixation (ORIF), right ankle triplane fracture(This is the working procedure until the report is read.)
ANESTHESIA: General endotracheal(The type of anesthesia utilized is provided. General anesthesia was used.)
COMPLICATIONS: None
SPECIMEN: None
IMPLANT USED: Synthes 4.0 mm cannulated screws
INDICATIONS FOR PROCEDURE:
The patient is a pleasant 15-year-old male who fell and sustained a right ankle triplane fracture. This was confirmed on both X-ray and CT scan. The indications for ORIF were explained to the patient, as well as the possible risks and complications, which include infection, bleeding, stiffness, hardware pain, the need for hardware removal, and there is no guarantee of a functional ambulatory result. The patient and family understood and wished to proceed.
PROCEDURE IN DETAIL:
The patient was brought back to the operating room and placed on an operating table, given a general anesthetic without any complications, and given preoperative antibiotics per usual routine. He had the right lower extremity prepped and draped in the usual sterile fashion with alcohol prep followed by routine Betadine prep.
Under X-ray guidance(Radiologic guidance was used.), a pointed reduction clamp was placed from the anterolateral corner of the distal tibia(Documentation within the body of the report further specifies the fracture and treatment were of the distal tibia.) to the medial side, and I reduced the triplane fracture.(The fracture was reduced.) It was confirmed on both AP and lateral X-ray images the gap was reduced. The patient then had guidewires taken from the Synthes 4.0 mm cannulated screw set. One was placed medially along the epiphysis on the anterior half of the epiphysis and parallel to the joint to catch the lateral aspect of the epiphysis. One screw was placed above the physis from anterior to posterior to capture that spike. Once the wires were in the appropriate position, the length was measured and partially threaded 4.0 mm cancellous screws were selected so all threads were across the fracture site.(Internal fixation was accomplished with screws.) The appropriate length screws were placed, confirmed by an X-ray to be in good position. The fracture was anatomically reduced, and the ankle joint was anatomic. The patient had wounds copiously irrigated. Closure was done with interrupted horizontal mattress 3-0 nylon suture. The patient had a sterile compressive dressing applied, was placed into a three-sided posterior mold splint, was extubated, and brought to the recovery room in stable condition. There were no complications. There were no specimens. Sponge and needle counts were equal at the end of the case.
What are the CPT® and ICD-10-CM codes reported?
27827-RT
S82.391A, W19.XXXA
There is one CPT® code and two ICD-10-CM codes reported. A triplane fracture is a fracture of the distal tibia in three planes and generally occurs during adolescence. Look in the CPT® Index for Fracture/Tibia/Distal. Refer to the guidelines in the Musculoskeletal System section to help you decide if this is a closed or open treatment. When selecting the CPT® code, keep in mind an internal fixation was performed. Use HCPCS Level II modifier to indicate the side of the body the procedure was performed. In the ICD-10-CM Alphabetic Index, look for Fracture, traumatic/tibia/lower end/specified NEC. Validate the code in the Tabular List. Look in the External Cause of Injuries Index for Fall, falling (accidental) for the External Cause Code.
CASE 6
PREOPERATIVE DIAGNOSIS: Comminuted intraarticular distal radial Colles’ fracture, left wrist.
POSTOPERATIVE DIAGNOSIS: Comminuted intraarticular distal radial Colles’ fracture, left wrist.
PROCEDURE: Application of a uniplane fixation and closed reduction of left distal radial fracture under fluoroscopy.
ANESTHESIA: General endotracheal.
DESCRIPTION OF THE PROCEDURE:
After induction of adequate general anesthesia, the patient’s left upper extremity was routinely prepped and draped into a sterile field. The extremity was elevated and exsanguinated with an Esmarch bandage. The tourniquet was inflated to 300 ml of mercury. We placed two half pins distally over the dorsoradial aspect of the second metacarpal. The first was placed in freehand technique making an incision, spreading with a hemostat, and then placing the half pin. The second pin was placed identically by using the pin guide. Similarly, we placed pins in the dorsoradial aspect of the distal third of the radius. We connected these two pins with clamps, and then under C-arm control, we reduced the fracture. All pins are now attached to the external fixation. This fracture at both the dorsal and volar comminution and intraarticular fractures was significantly shortened and telescoped. We obtained the best reduction possible, and tightened down the clamps to the bars. The pin tracks were dressed with Xeroform and 2 x 2 gauze, and volar 3 x 15 plaster splints were applied. The tourniquet was allowed to deflate during application of the dressing. Total tourniquet time was 14 minutes. There were no intraoperative complications.
What are the CPT® and ICD-10-CM codes reported?
20690, 25605-51-LT
S52.532A
There are two CPT® codes and one ICD-10-CM code reported. The 1st CPT® code is the application of the external fixation device used to help the fracture heal. In the CPT® Index, look for External Fixation/Application for the code choices. No informational modifier is used on this code. The second code is the repair of the Colles fracture. In CPT® Index, look for Fracture/Radius/Colles. Refer to the CPT® guidelines in the Musculoskeletal System section to help you decide if this is a closed or open treatment and for the definition for manipulation. Use a HCPCS level II modifier to indicate the side of the body where the procedure was performed. A modifier will need to be appended to the 2nd CPT® code to indicate multiple procedures were performed in the same surgical session. Remember, when reporting multiple modifiers, the modifier that affects payment goes first and informational modifiers are last.
In the ICD-10-CM Alphabetic Index look for Fracture, traumatic/Colle’s directing you to See Colles’ fracture. At the beginning of category S52 in the ICD-10-CM Tabular List there are Notes for what defines a ‘closed’ and ‘open’ fracture, and how to code a fracture not indicated as closed or open. There is a listing for the 7th character. See guidelines I.C.19.a regarding Initial vs. Subsequent Encounters for traumatic fractures and how to code them.
CASE 7
OPERATIVE REPORT
PREOPERATIVE DIAGNOSIS: Dislocation of right elbow.
POSTOPERATIVE DIAGNOSIS: Dislocation of right elbow with medial epicondyle fracture.
OPERATIVE PROCEDURE: Closed reduction of elbow dislocation with a closed reduction of medial epicondyle fracture.
ANESTHESIA: General.
INDICATIONS: This is a 12-year-old male who had an injury, sustaining a dislocation of his right elbow and medial epicondyle fracture. The risks and benefits of surgical treatment were discussed with the family, who stated they understood and wanted to proceed.
DESCRIPTION OF PROCEDURE: On the day of the procedure, after obtaining informed consent, the patient was taken to the main operating room where general anesthesia was induced. Once he was under adequate anesthesia, the reduction maneuver was performed. The elbow was reduced and was stable. Through full range of motion there was noted to be a slight crepitus on the medial elbow and some mobility was felt in the medial epicondyle. Examination under C-arm imagery revealed a concentric reduction of the elbow, but with mildly unstable medial epicondyle fracture. When the elbow was held in the appropriate position, the medial epicondyle was well reduced in an acceptable position. It was elected to treat this non-surgically. A long arm splint was applied. The patient was awakened from anesthesia and taken to recovery in stable condition with no immediate complications.
What are the CPT® and ICD-10-CM codes reported?
24565-RT, 24605-51-RT
S42.441A, S53.104A
There are two CPT® codes and two ICD-10-CM codes reported. The 1st CPT® code is the repair of the fracture. In the CPT® Index, look for Fracture/Humerus/Epicondyle. Refer to the CPT® guidelines in the Musculoskeletal System section to decide if the procedure is open or closed. Also read the definition of manipulation to determine if a manipulation was performed on the fracture. Use a HCPCS Level II modifier to indicate which side of the body the procedure is performed. The 2nd procedure to report is the treatment on the dislocated elbow. In the CPT® Index, look for Dislocation/Elbow/Closed Treatment. Refer to the operative report to determine if anesthesia was used. Use a HCPCS Level II modifier to indicate the side of the body the where the procedure is performed. The 2nd CPT® also requires a modifier to indicate multiple procedures performed during the same operative session. Remember, when reporting multiple modifiers, the modifier that affects payment goes first and informational modifiers go last. The first diagnosis code will show the location of the fracture. In the ICD-10-CM Alphabetic Index, locate Fracture, traumatic/humerus/lower end/epicondyle/medial (displaced). The second code will show the location of the dislocation. In the Alphabetic Index, locate Dislocation/elbow/traumatic. Validate the codes in the Tabular List.
CASE 8
PREOPERATIVE DIAGNOSIS: Right long finger, trigger finger. Left subacromial bursitis.
POSTOPERATIVE DIAGNOSIS: Right long finger, trigger finger. Left subacromial bursitis.
PROCEDURES:
Right long finger trigger release. Injection of the left shoulder with Xylocaine, Marcaine and Celestone via anterior subacromial approach.
ANESTHESIA: General.
COMPLICATIONS: None.
ESTIMATED BLOOD LOSS: Minimal.
REPLACEMENT: Crystalloids.
DESCRIPTION OF PROCEDURE: The patient was taken to the operating room where he was given general anesthesia. The right upper extremity was prepped and draped in the usual sterile fashion. While draping, the left shoulder was prepped with Betadine; and through an anterior subacromial approach, the left shoulder was injected with 1 cc of Xylocaine, 1 cc of Celestone, and 1 cc of Marcaine. The patient tolerated the procedure well.
Meanwhile, the right hand had been prepped and draped. It was exsanguinated with an Esmarch bandage, and the tourniquet inflated to 250 mm. I made an incision over the A1 pulley in the distal transverse palmar crease, about an inch in length. This was taken through skin and subcutaneous tissue. The Al pulley was identified and released in its entirety. Care was taken to avoid injury to the neurovascular bundle. The wound was irrigated with antibiotic saline solution. The subcutaneous tissue was injected with Marcaine without epinephrine. The skin was closed with 4-0 Ethilon suture. A clean dressing was applied. The patient was awakened and taken to the recovery room in stable condition.
What are the CPT® and ICD-10-CM codes reported?
26055-F7, 20610-51-LT
M65.331, M75.52
There are two CPT® codes and two ICD-10-CM codes reported. There is a trigger finger repair on the right hand and a cortisone injection in the left shoulder joint. The trigger finger release is the first CPT® code. In the CPT® Index, look for Trigger Finger Repair. Add the HCPCS Level II modifier for right hand, third digit. The second code is for the shoulder injection. In the CPT® Index, look for Injection/Joint. Code selection is based on the joint injected and with or without ultrasound. Use a modifier to indicate multiple procedures performed during the same operative session and HCPCS Level II modifier to indicate the side of the body. Remember, when reporting multiple modifiers, the modifier that affects payment goes first and informational modifiers go last.
There are two diagnoses: Look in the ICD-10-CM Alphabetic Index for Trigger finger (acquired)/middle finger. The second code is for the shoulder impingement/subacromial bursitis. Bursitis can be a cause of shoulder impingement. Look in the Alphabetic Index for Bursitis/subacromial referring you to see Bursitis, shoulder. Validate the codes in the Tabular List.
CASE 9
Procedure performed in office.
PREOPERATIVE DIAGNOSIS: Right-sided thoracic pain.
POSTOPERATIVE DIAGNOSIS: Right-sided thoracic pain.
OPERATION: Trigger point injection into the right-sided thoracic spine musculature, into the rhomboid major, rhomboid minor, and levator scapular muscles.
PROCEDURE:
The patient was seated on the bed. He has metastatic right lung cancer. The risks of the procedure, including bleeding, infection, nerve damage, and no guarantee of symptom relief were explained. The patient agreed to the procedure and the informed consent was signed.
I palpated for areas of maximal tenderness. Five points were marked over the right-sided thoracic paraspinal musculature. I then cleaned off his back with chlorhexidine x2. Then I used a 25 gauge 1.5-inch needle on a 10 cc controlled syringe with 40 mg/ml Depo-Medrol. After negative aspiration, 1 cc was injected into each point. A total of four points were injected. A total of 4 cc (160mg) was used. The patient tolerated the procedure well. Band-Aids were not placed. The patient was not bleeding.
We are refilling the patient’s pain medication. He is seeing an oncologist and gets Percocet 7.5/500. He takes four a day, providing him with pain relief. We will dispense to him today a three-week supply. We are going to dispense #84. He is to return to the office in two weeks, at that time we will get a urine specimen for follow-up. Emphasized to the patient, once again, that he had to bring his pills to every appointment according to the opioid contract.
What are the CPT® and ICD-10-CM codes reported?
20553, J1030 X 4
M54.6, C78.01
There is one CPT® code, one HCPCS Level II code and two ICD-10-CM codes reported. Trigger point injections are reported by the number of muscles injected, not how many injections are given. The muscles injected are listed under Operation. This will be the first code listed. Look in the CPT® Index for Trigger Point/Injection; code selection is based on the number of muscles injected. Because the procedure was performed in office, and the documentation included the route of administration, the drug injected, and the drug amount, we can code for the drug. You will need to use your HCPCS Level II code book to find the drug code. Look in the Table of Drugs and Biologicals (Appendix A) for Methylprednisolone Acetate 40mg. Remember when the administered dosage exceeds the dose unit in the code description, enter the units next to the HCPCS Level II code (for example, x 2, x 3, x 4, etc.).
There were four injections of Methylprednisolone Acetate 40mg. The reason for the encounter is the thoracic pain and is the first-listed diagnosis code. Look in the ICD-10-CM Alphabetic Index for Pain/spine/thoracic. The second diagnosis is the metastatic right lung cancer. It is unrelated but does need to be considered when performing procedures. Look in the ICD-10-CM Table of Neoplasms for Neoplasm, neoplastic/Lung/Malignant Secondary column. Validate the codes in the Tabular List.
CASE 10
PREOPERATIVE DIAGNOSIS: Left Achilles’ tendon rupture.
POSTOPERATIVE DIAGNOSIS: Left Achilles’ tendon rupture.
OPERATION PERFORMED: Open Left Achilles’ tendon repair.
ANESTHESIA: General anesthesia
INDICATIONS: The patient is a 25-year-old male who was playing basketball when he was hit by another player and felt a pop in the back of his ankle approximately two months ago. Examination reveals a positive Thompson test, but no plantar flexion on squeezing the calf. There is a palpable defect in the Achilles’ tendon. There is swelling in this region and neurovascular examination is intact. Given these clinical findings, the patient is taken to the operating room for the aforementioned procedure.
DESCRIPTION OF PROCEDURE: Following induction of general anesthesia the patient was placed prone on the operating table and all bony prominences were well-padded. The patient received a 1g dose of Ancef. Under tourniquet control of 250 mmHg, a longitudinal incision was made followed by opening up the paratenon of the Achilles’ tendon. An obvious rupture was noted. The hematoma was evacuated and the ends were then debrided with a Metzenbaum scissors. A No. 2 FiberWire® was placed in a Bunnell-type fashion in both the proximal and distal portions of the Achilles’ tendon. A No. 2 Orthocord was then used and placed in a running fashion along the proximal and distal portions of the Achilles’ tendon. A total of four sutures were used. These were then tied together to re-approximate the tendon with no significant tension on the repair.
A secure repair was noted. The ends of the repair were further augmented with a 2-0 Vicryl suture. The wound was thoroughly irrigated with antibiotic irrigation solution. The fascial plane was closed with a 2-0 Vicryl suture, followed by closing the skin with a 2-0 in subcuticular fashion. Approximately 10 cc of 0.5% Marcaine was injected for postoperative pain control. A routine dressing was applied to the extremity, and it was placed into a short leg cast with the foot slightly plantar-flexed. The anterior aspect of the cast was then univalved. The tourniquet was deflated for a total tourniquet time of 42 minutes.
The patient was awakened in the operating room breathing spontaneously and taken to the recovery room in stable condition.
What are the CPT® and ICD-10-CM codes reported?
27650-LT
S86.012A, W50.0XXA, Y93.67, Y99.8
There is one CPT® code and four ICD-10-CM codes reported. When selecting a repair code for the Achilles tendon look in the CPT® Index for Achilles Tendon/Repair; you will need to know if this is the primary or secondary repair for this visit and if a graft was used. Use a HPCPS Level II modifier to indicate the side of the body where the procedure was performed. The first diagnosis code is for ruptured Achilles tendon. In the ICD-10-CM Alphabetic Index, look for Injury/Achilles tendon/strain. External cause codes are reported for the cause of the injury, the Activity code, and external cause status. The first external cause code indicates the cause of injury. In the ICD-10-CM Index to External Causes look for Hit, hitting (accidental) by referring you to see Struck by. The next external cause code is for the activity the patient was performing when the injury occurred. In the ICD-10-CM External Cause of Injuries Index, locate Activity/basketball. The last external cause code is found by looking for Status of external cause/recreation or sport not for income or while a student.
