As most medical practices are aware, not all cases are easy to navigate using the latest medical standards. The information below highlights a complicated surgical case along with the correct CPT and ICD-10 codes. Do you have a complicated surgery case need help with coding? RT Welter would love to help! 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.

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  • PREOPERATIVE DIAGNOSES: Peroneal Tendon Tear, left foot.
  • POSTOPERATIVE DIAGNOSES: Peroneal brevis tendon tear.
  • PROCEDURE: Peroneal brevis tendon repair, left ankle.
  • ANESTHESIA: General with local.
  • HEMOSTASIS: Thigh tourniquet at 300mmHg.
  • MATERIALS: 4-0 Prolene. An amniotic tissue layer.

After informed consent was obtained from the patient, the patient was brought to the operating room, placed on operating table in a partial lateral decubitus position. A prep block was then performed utilizing 0.5% Marcaine. The left lower extremity was then cleaned, prepped and draped in usual aseptic manner. The left lower extremity was then elevated before a pneumatic tourniquet was inflated to 300 mmHg.


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Correct CPT and ICD-10 Codes with modifiers and units:

27658 (LT modifier) – Repair, flexor tendon, leg; primary, without graft, each tendon

S86.312A – Strain of muscle(s) and tendon(s) of peroneal muscle group at lower leg level, left leg, initial encounter