Orthopedic Coding Alert

Reader Question:

Report Decompression at Ankle

Published on Thu Jun 09, 2011

Question: How does one report a code when the operative note reads "The thick retinaculum at the ankle was incised. The sheath of posterior tibial tendon was thickened with mild adhesions. The sheath was then released proximally about 2 cm above the tip of the malleolus and distally about 2 cm. The tendon was pulled out of the incision, inspected for tears, and then repositioned."

Georgia Subscriber

Answer: You report code 27680 (Tenolysis, flexor or extensor tendon, leg and/or ankle; single, each tendon) as the description here says that the surgeon is releasing the tendon sheath.

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Correction:
In Orthopedic Coding Alert Vol.14, N.5, page 30, we reported the following: "In addition, 29515 [...]

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