Don’t Let Your Lisfranc Coding Skills Fall Flat
Often misdiagnosed and overlooked, Lisfranc injuries aren’t easy to spot. The Lisfranc joint is where the metatarsal and tarsal bones of the foot connect to one another. Located in the midfoot area, many injuries can occur to these bones and ligaments, ranging from strains and tears to dislocations and fractures. Typically, a Lisfranc injury occurs when the foot is pointing downward. Patients with these injuries report to the podiatry office or emergency department (ED) showing signs like bruising, swelling, and sharp pain in the midfoot area. If the condition is left untreated, it can lead to a collapsed arch of the foot, and the patient will require a complicated corrective surgery down the line. Sharpen your Lisfranc coding skills by trying your hand at the two coding scenarios below. Examine Coding Case #1 A 33-year-old patient reports to your podiatry office complaining of pain and swelling in the midfoot area of the left foot from an injury they received while playing flag football. After an examination of the patient’s foot and a CT scan, your podiatrist diagnoses the patient with a Lisfranc dislocation. The podiatrist was able to manipulate the dislocation back into its correct position, so no surgery is necessary. To quickly identify the ICD-10-CM code for Lisfranc injuries, start with Chapter 19: Injury, Poisoning and Certain Other Consequences of External Causes (S00-T88), specifically the Injuries to the ankle and foot (S90-S99) section. This will lead you to S93.- (Dislocation and sprain of joints and ligaments at ankle, foot and toe level). Knowing the Lisfranc joint is also called the tarsometatarsal (TMT) joint will help you select S93.32- (Subluxation and dislocation of tarsometatarsal joint). Add 6th character 2 and 7th character A to indicate a left foot injury under active treatment. A dislocation refers to the situation where two bones that are supposed to be connected at a joint become misaligned. This sometimes necessitates surgical intervention on the patient, but not always. As a coder, you’ll need to thoroughly review the podiatrist’s notes to accurately understand the specifics of the procedure or, in this case, the physical manipulation used to put the dislocation back in place. Luckily, a basic understanding of a few clinical terms can help you quickly identify the correct code. Because the skin was unbroken and surgery was not required, you would choose 28600 (Closed treatment of tarsometatarsal joint dislocation; without anesthesia). Make note: The code indicates that anesthesia was not used during the procedure. If the notes had indicated it was used, you’d reach for 28605 (Closed treatment of tarsometatarsal joint dislocation; requiring anesthesia) instead. Break Down Coding Case #2 A patient injured their foot last summer when they fell out of a fishing boat and hit their foot on rocks in shallow water. The patient was seen again recently, and after reviewing the MRI results, the practitioner noted, “The ligament appears thin and stretched out and not the thick radio dense structure it typically is when uninjured.” The patient’s arch had fallen significantly compared to the uninjured foot. The provider stated they would move forward with the repair of Lisfranc ligament with stress imaging of Lisfranc interval. The midfoot region of the right lower extremity was examined. An X-ray was used to identify the 2nd metatarsal and cuneiforms. An incision was made over the base of the 2nd metatarsal, and a K-wire was used to guide fixation toward the medial cuneiform. Fluoroscopy confirmed the correct trajectory. A hole was drilled for Artelon ligament repair, and a flex band was inserted from lateral to medial. A suture button was applied, and a G lock implant secured the flex band. X-ray confirmed reduction of the Lisfranc interval. An incision was made over the intermediate cuneiform, taking care to protect the neurovascular bundle. A K-wire was then placed, and drilling was performed. The flex band was secured under the soft tissue envelope and reduction confirmed with fluoroscopy. Stress imaging showed no laxity or excessive movement across the Lisfranc interval. You will use the following codes on your claim: Lindsey Bush, BA, MA, CPC, Production Editor, AAPC
Preoperative diagnosis & postoperative diagnosis: Lisfranc sprain, right and midfoot instability, right.
The tourniquet was released, and the surgical area was thoroughly rinsed with a large volume of normal saline. Hemostasis was successfully achieved before the wound was closed. Platelet-rich plasma (PRP) was administered to the surgical area. A local anesthetic block was performed using a balanced mixture of 20 cc Exparel (133 mg) and 0.5 percent Marcaine, in a sterile environment. The deep wound was closed using 2-0 Vicryl and the skin was brought together with 2-0 nylon. The lower extremity was dressed with Xeroform, 4x4s, Kling, and an Ace bandage, and then secured in a Cam boot. The patient handled the procedure and anesthesia well. After a period of postoperative observation, the patient was sent home. The patient is advised to put minimal weight on the right foot until their next appointment.
