Anesthesia Coding Alert

Question: What diagnosis and procedure codes apply to open repair of pectoralis major tendon rupture?

Oregon Subscriber Answer: CPT Codes does not include a code specifically for this, so coders' advice varies. One option is 01710 (Anesthesia for procedures on nerves, muscles, tendons, fascia, and bursae of upper arm and elbow; not otherwise specified). Code 01610 (Anesthesia for all procedures on nerves, muscles, tendons, fascia, and bursae of shoulder and axilla) is another option. Other coders recommend starting with surgical code 21899 (Unlisted procedure, neck or thorax) because the pectoralis is the chest wall. This crosses to anesthesia code 01999 (Unlisted anesthesia procedure[s]).

The correct diagnosis depends on whether the tendon ruptured due to an injury. Possible ICD-9 codes include 727.60 (Nontraumatic rupture of unspecified tendon), 727.69 (Rupture of tendon, nontraumatic; other) and 848.4 (Other and ill-defined sprains and strains; sternum). Although you know which tendon ruptured, ICD-9 codes do not specify particular tendons, so you'll use an "unspecified" or "other" tendon diagnosis.