Wiki Tenolysis and debridement of Right Peroneal Tendons

[GabiMcElrath]

Hello,
I'm very new to coding podiatry. I was wondering if anyone could give me some insight of what you think the coding would be for this procedure? The doctor is stating that it would be 27691, but I feel like it should be 27680 or 27681. For the sural nerve excision I came up with 27618. If anyone could give me some insight as to why the provider used this code it would be greatly appreciated. Thank you in advance.

Preoperative Diagnosis: Peroneus brevis tendon rupture.

Postoperative Diagnoses:
1. Sural neuroma, right ankle.
2. Tenosynovitis, right peroneus brevis tendon.

Procedure: 1. Sural Nerve excision Right akle
2. Tenolysis, Debridement right peroneal tendons

Initially, a preoperative MRI showed what appeared to be continued longitudinal split tearing of the peroneus brevis tendon with lot of inflammatory tissue along the peroneal tendon sheath, which a radiologist read as further tendon tearing. The patient already had a prior surgery for two-ligament repair with lateral ankle stabilization surgery and inspection of the peroneal tendons that resulted in healthy tendons last visit. And so, resultant MRI showing continued tearing of this tendon necessitated revisional or secondary surgery. The incision was made along the prior incision from posterior to fibular malleolus to the entire length of peroneal tendons. Careful dissection was carried down through scar tissue and superficial subcutaneous tissues with #15 blade and then again careful dissection past the dermis with tenotomy scissors.
Immediately visible was very adherent and thick tubular area of scar tissue from posterior to the fibular malleolus to the peroneal tubercle area of the calcaneal region along the peroneal tendon sheath. This was initially dissected and intact, retracted out of the wound, as the initial idea was to visualize and repair the peroneus brevis tendon. However, opening up this sheath, both tendons again appeared healthy. The peroneus brevis tendon naturally flattened some, as it rounds the fibular malleolar area, and 360-degree rotational inspection of both tendons appeared that they were shiny pearl-like and not fibrillated or yellow, discolored, or degenerated in any way. Appeared very healthy and moved in their sheath and fibular groove nicely. This wound was flushed and then 3-0 Vicryl as well as 3-0 FiberWire suture was used to reapproximate the
peroneal tendon attachment to fibular malleolus to prevent peroneal tendon subluxation and 3-0 Vicryl simple interrupted sutures used to close remainder of the sheath. As this tubular thickened portion appeared initially to be just scar tissue lining the top of the tendon, there was some tenosynovitis noted that had to be resected from the peroneus brevis tendon due to tenosynovitis and this was done prior to closure by the way of the peroneal tendon sheath.

Next procedure is sural neurectomy, right ankle. So, the very proximal end of the incision, this was inspected and with the idea of finding the sural nerve, the sural nerve was found and appeared to be intact proximally and healthy, but the hidden area of thickened scar tissue that I initially thought was subcutaneous scar tissue, was adherent scar tissue around the entire nerve from posterior to fibular malleolus to the peroneal tubercle, and then became a normal healthy nerve distal to that. This was adherent completely encapsulating the nerve. This was actually degenerative nerve, likely caused from his original injury and stretch injur embroiling his ankle. MRI and even surgical intervention will miss traumatic neuromas early on in their process, but over time these nerves can degenerate due to injury and then surgical scar tissue will invade as well creating a significant initial presurgical and postsurgical pain. At this time, a #15 blade was used to resect both sides both proximally and distally removing this section of nerve and sent for pathology. Later report did show sural neuroma as initially visualized in this
procedure and assumed. After removal of this, wound was flushed, good healthy tissue noted all around. 3-0 Vicryl simple interrupted sutures was used to close subcutaneous tissue. 3-0 Prolene horizontal mattress sutures used to close skin. 10 cc 0.5% Marcaine plain was injected around the incision area. Xeroform, 4x4s, Kerlix, and Ace bandage were applied. Tourniquet removed. Capillary refill time immediate. The patient tolerated the procedure and the anesthesia well and returned to the recovery room with vital signs stable.

 

[KimberlySherman]

28220 Tenolysis, flexor, foot; single tendon is coded for tenolysis of the peroneus brevis tendon. The peroneus brevis muscle starts in the lower leg, runs behind the lateral malleolus at the ankle as a tendon, and inserts at the base of the 5th metatarsal. The peroneal tendons are primarily foot tendons, so look to the foot CPT codes for procedures on these tendons when subluxation or dislocation (which happens at the lateral maleollus of the ankle) is not documented. CPT Assistant, Feb. 2016 explains that CPT code 28200 is coded for repair of a peroneal tendon. Likewise, peroneal tenolysis would be coded with 28820. I highlighted the peroneus brevis with yellow, and marked the locations of the retinaculum holding the peroneals in place with blue.


Source: https://en.wikipedia.org/wiki/Fibularis_brevis

I do not see documentation to support coding 27691 Transfer or transplant of single tendon (with muscle redirection or rerouting); deep (eg, anterior tibial or posterior tibial through interosseous space, flexor digitorum longus, flexor hallucis longus, or peroneal tendon to midfoot or hindfoot). The tendon is not detached from its normal position and reattached at a different location.

The op note mentions "3-0 Vicryl as well as 3-0 FiberWire suture was used to reapproximate the peroneal tendon attachment to fibular malleolus to prevent peroneal tendon subluxation." The tendon does not attach to the malleolus, but slides behind it, in it's sheath. The surgeon might have meant that they anchored the tendon sheath to the malleolus to stabilize it. There isn't anything in the report to indicate that subluxation was occurring, or that this suturing was done to treat a pathology of the tendon. I would ask the surgeon clarify what was done and why at this part of the procedure. Such subluxation is usually caused by tearing of the retinaculum that covers the tendons at the ankle, holding them in place. Here is an article explaining the meaning of peroneal subluxation and dislocation: https://eorthopod.com/peroneal-tend...uscle puts tension,This is called subluxation.

The sural nerve is a cutaneous nerve. Excision of a neuroma of a cutaneous nerve is coded with 64774 Excision of neuroma; cutaneous nerve, surgically identifiable, ICD-10 G57.81 Other specified mononeuropathies of right lower limb.

 

[amyjph]

Agree as above. It's definitely not 27691. Peroneals are flexors and code to the foot as Kimberly states above. However there is a typo, 28820 is an amputation. The flexor repair and tenolysis foot codes would be 28200, 28202, 28220, 28222.