Revenue Cycle Insider

Question: The notes indicate that the patient previously ruptured their left Achilles tendon five years ago and they have now ruptured it a second time. An MRI with contrast confirmed the location and extent of the spontaneous rupture, and the surgeon elected to proceed with a surgical repair. The surgeon makes an incision along the back of the ankle, following the path of the damaged tendon. After removing scar tissue and additional degenerative tissue, the surgeon exposes the damaged tendon. The surgeon then sutures the ruptured ends of the Achilles tendon using the Bucknell suture technique and reinforces the repair using synthetic graft material. The surgeon then irrigates the wound and closes the incision with staples.

How should I code this encounter?

AAPC Forum Participant

Answer: Because the documentation describes a recurrent Achilles tendon rupture requiring debridement, repair, and graft reinforcement, the operative report supports a secondary repair. You’ll report the following on the claim:

• 27654 (Repair, secondary, Achilles tendon, with or without graft)
• 73719 (Magnetic resonance (eg, proton) imaging, lower extremity other than joint; with contrast material(s))
• Modifier LT (Left side) appended to 27654 to and 73719 to indicate laterality
• M66.872 (Spontaneous rupture of other tendons, left ankle and foot) appended to 27654 and 73719 to represent the patient’s injury.

Lindsey Bush, BA, MA, CPC, Production Editor, AAPC