Trouble with CPT 27658 vs 27659 with posterior tibial tendon repair

Retrophaze

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Hi everyone,

I am having trouble wrapping my mind around why the coding company and the doctor are wanting to code CPT 27659 for the following report. I thought it would be 27658 as there was no previous surgery and according to my Procedure Desk Reference AAPC 2016, the description of 27659 sounds like it talks about previous repairs. There must be some verbiage in the note that I am not latching on to. The patient did have an allograft of Dermaspan. Can anyone help explain this to me? Thanks!

The patient has had the abovementioned chief complaint for some time. Conservative treatment measures have been attempted and exhausted and the patient has chosen surgical correction of the deformities at this time.
DESCRIPTION OF PROCEDURE:
Attention was directed to the medial aspect of the right ankle where a hockey stick type incision was created along the course of the posterior tibial tendon. The incision was carried into subcutaneous tissue, taking care to cauterize any superficial bleeders as necessary. Blunt dissection was carried down to the level of the peritenon which was incised and split along the course of the posterior tibial tendon with the Metzenbaum scissors. Once encountering the posterior tibial tendon, the posterior tibial tendon was retracted out of the groove behind the medial malleolus and pulled, moving the foot in the appropriate direction indicating the correct tendon was identified. There was a longitudinal split tear from approximately 2cm distal to the medial malleolus and extending proximally approximately 3cm. Just proximal to the split there was a yellow discoloration to the posterior tibial tendon. Beginning with the yellow discoloration and including the split, a portion of the tendon was excised. The split tendon was excised and sent to pathology for evaluation. The area was flushed with copious amounts of sterile saline. The posterior tibial tendon was then re-tubularized utilizing 3-0 Ethibond starting at the most proximal aspect. In a running suture technique, the excised portion of the split tear was re-approximated making the tendon tubular again. Next using the dermaspan, the graft was placed around the split portion. The graft was placed on the tendon that would approximate with the medial malleolus to reinforce this repair. The graft was placed in its correct orientation and placed on the tendon and sutured to the tendon in four different locations. The posterior tibial tendon was then placed back into the groove behind the medial malleolus, put through its range of motion and found to be smooth and without rubbing or clicking.
 

duboses

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It may be the word "graft" in the description of the procedure and documentation

The documentation for 27658 says "without graft". 27659 says "with or without graft". The description of the procedure you provided uses the term "graft" a number of times.
 

Retrophaze

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Perfect. I will go with the graft part and dismiss all the other stuff that 27658 states. The coding company said "As per report, it was done at ankle near malleolus and considered as secondary as conservative measures already attempted - 27659" I had already asked the coder to explain her decision so I didn't want to question her anymore but don't understand her answer as "secondary". I appreciate the feedback.
 
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