Orthopedic Coding Alert

Question: Encounter notes indicate that the provider treated a patient for “laceration, peroneal muscle group, L lower leg” and “tendon strain, peroneal muscle group, L lower leg.” What is the correct coding for these diagnoses? Should I use one ICD-10 code or two? Or more?

Kansas Subscriber

Answer: You should report a pair of ICD-10 codes to represent this patient’s injuries. First, report S86.322 (Laceration of muscle(s) and tendon(s) of peroneal muscle group at lower leg level, left leg) to represent the laceration; then, report S86.312 (Strain of muscle(s) and tendon(s) of peroneal muscle group at lower leg level, left leg) for the tendon strain.

Explanation: There is no combination code for these two conditions, so you’ll need to report two diagnosis codes to most accurately represent the patient’s condition. Also, for future reference, the peroneal muscle group involves: “Two peroneal tendons that run along the back of the fibula. The first is called the peroneus brevis. It … starts lower in the leg. It then runs down around the back of the fibula on the outside of the leg and connects to the fifth metatarsal on the side of the foot,” according to www.footcaremd.com.

The second tendon is the peroneus longus. “It starts higher on the leg and runs all the way underneath the foot to connect to the first metatarsal on the other side. Both tendons share the major job of turning the ankle to the outside,” reports https://footcaremd.org.