Orthopedic Coding Alert

The most likely first encounter with an Achilles patient would be an evaluation and management (E/M) service, typically accompanied by some type of imaging service to make a decision on the patient’s injury.

According to Wayne Conway, CPC, CRC, CGSC, COSC, physician coder II at WakeMed Physicians Practice in Raleigh, a Thompson test is the most frequently used to inspect the patient’s Achilles. The provider will perform the Thompson test — which involves squeezing the calf muscles while the patient is kneeling or lying face down with feet hanging unsupported — during the E/M service.

There’s a lot a provider can learn about the state of the Achilles during a Thompson test. “There could be mild swelling and tenderness in the area. Sometimes a palpable defect can be felt in the area of the Achilles tendon,” explains Conway. “If the tendon is torn there will be a noticeable loss of flexion movement with the foot and ankle.”

At this point, the provider might order an X-ray to rule out fracture or dislocation; but what is more likely to happen is an imaging test.

“MRI [magnetic resonance imaging] and ultrasound [US] can confirm a diagnosis,” says Cathy Satkus, CPC, COBGC, of Harvard Family Physicians in Tulsa, Oklahoma.

When your provider performs an MRI or US, you’ll likely use one of the following codes for the service, as appropriate:

• 76881 (Ultrasound, complete joint (ie, joint space and peri-articular soft-tissue structures), real-time with image documentation)
• 76882 (Ultrasound, limited, joint or other nonvascular extremity structure(s) (eg, joint space, peri-articular tendon[s], muscle[s], nerve[s], other soft-tissue structure[s], or soft-tissue mass[es]), real-time with image documentation)
• 73718 (Magnetic resonance (eg, proton) imaging, lower extremity other than joint; without contrast material(s))
• 73719 (… with contrast material(s))
• 73721 (… without contrast material(s), followed by contrast material(s) and further sequences)
• 73722 (… with contrast material(s))
• 73723 (… without contrast material(s), followed by contrast material(s) and further sequences)

Modifier alert: Don’t forget to append modifier LT (Left side) or RT (Right side) to your MRI/US code to indicate laterality.

Report These Codes for Surgical Tx

Once the provider diagnoses a ruptured Achilles, their next move will be repairing the defect. When your provider performs Achilles rupture repair, you’ll choose from one of the following codes:

• 27650 (Repair, primary, open or percutaneous, ruptured Achilles tendon)
• 27652 (Repair, primary, open or percutaneous, ruptured Achilles tendon; with graft (includes obtaining graft))
• 27654 (Repair, secondary, Achilles tendon, with or without graft)

Code differences: You’d report 27650 for an acute Achilles tear that the provider repairs without a graft. “If a graft was needed during that acute repair, code 27652 would be more appropriate. Use 27654 for secondary repairs and delayed repairs,” Conway explains.

“For instance, if a primary repair failed or the patient experienced a re-tear, code 27654 would be appropriate.”

Conway continues to say that you could also code 27654 when a repair was delayed days or weeks after an acute injury. “Code 27654 could also be used for repair of a chronic tear where scar tissue and adhesions have formed. This sometimes will alter anatomy and make repairs more difficult,” he says.

One more 27654 use: Per CPT^® Assistant, code 27654 may also be reported for “debulking” of a diseased Achilles tendon.

Check Out This Clinical Scenario

Conway offers this example, in which the orthopedist diagnoses and treats a patient with a ruptured Achilles:

An established patient reports and complains of pain in the Achilles/gastrocnemius area after stepping off a curb and feeling a pop in the back of his right leg. The provider notes mild swelling and tenderness and performs a Thompson test. The provider notices a palpable defect and a loss of flexion movement. They perform an MRI with contrast to determine the extent of the Achilles tendon tear. The provider places the patient in a walking boot until the follow-up appointment. Notes indicate that the E/M portion of the visit lasted 44 minutes and the provider performed moderate medical decision making (MDM).

The patient presents for repair surgery. The surgeon performs a primary repair without a graft.

On the claim, you’d report:

• 27650 for the Achilles repair
• Modifier RT appended to 27650 to indicate laterality
• 73722 for the MRI
• Modifier RT appended to 73722 to indicate laterality
• 99215 (Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and high level of medical decision making. When using time for code selection, 40-54 minutes of total time is spent on the date of the encounter.) for the E/M service
• Modifier 57 (Decision for surgery) appended to 99215 to show that a significant, separate E/M preceded the Achilles diagnosis.
• S86.011A (Strain of right Achilles tendon, initial encounter) appended to 27650, 73722, and 99215 to represent the patient’s Achilles injury
• W10.1XXA (Fall (on)(from) sidewalk curb, initial encounter) appended to 27650, 73722, and 99215 to represent the cause of the patient’s Achilles injury.