As part of the new coding format for our newsletter, RT Welter is excited to offer you a new surgery coding series in which we want to help you! The 2nd week of every month we will highlight a complicated surgical case. This week we are highlighting a general surgery case. We want to hear from you! If you have a complicated surgery case and need help with coding, please upload the operative note by clicking on the link below. Remember to remove ALL patient protected health information and organization identifiers. RT Welter will not use any medical records submitted in which PHI is not removed and protected. Click Here To Submit Redacted Surgery Case Study. Click Here To Submit Redacted Surgery Case Study
Preoperative Diagnosis:
- Right achilles rupture.
Postoperative Diagnosis:
- Right achilles rupture.
Procedures:
- Repair of achilles tendon rupture.
- Posterior compartment fasciotomy.
Indications: Suffered an achilles tendon rupture while performing jujitsu/martial arts 1 week prior. I discussed with him repair of his achilles tendon. Risks and benefits were discussed, including, but not inclusive to, nerve damage, infection, delay in healing, wound dehiscence, as well as re-rupture.
Correct CPT and ICD-10 Codes:
27650 – RT modifier- Repair, primary, open or percutaneous, ruptured Achilles tendon;
27893 – RT modifier- Decompression fasciotomy, leg; posterior compartment(s) only, with debridement
of nonviable muscle and/or nerve
S86.011A – Strain of right Achilles tendon, initial encounter
T79.A21A – Traumatic compartment syndrome of right lower extremity, initial encounter