Question

PREOPERATIVE DIAGNOSIS : Left Achilles' tendon rupture.

POSTOPERATIVE DIAGNOSIS : Left Achilles' tendon rupture.

OPERATION PERFORMED : Open Left Achilles' tendon repair.

ANESTHESIA : General anaesthesia.

INDICATIONS : The patient is a 25-year-old male who was playing basketball when he was hit by another player and felt a pop in the back of his ankle approximately two months ago. Examination reveals a positive Thompson test, but no plantar flexion on squeezing the calf. There is a palpable defect in the Achilles' tendon. There is swelling in this region and neurovascular examination is intact. Given these clinical findings, the patient is taken to the operating room for the aforementioned procedure.

DESCRIPTION OF PROCEDURE : Following induction of general anaesthesia the patient was placed prone on the operating table and all bony prominences were well-padded. The patient received a 1g dose of Ancef. Under tourniquet control of 250 mmHg, a longitudinal incision was made followed by opening up the paratenon of the Achilles' tendon. An obvious rupture was noted. The hematoma was evacuated and the ends were then debrided with a Metzenbaum scissors. A No. 2 FiberWire® was placed in a Bunnell-type fashion in both the proximal and distal portions of the Achilles' tendon. A No. 2 Orthocord was then used and placed in a running fashion along the proximal and distal portions of the Achilles' tendon. A total of four sutures were used. These were then tied together to re-approximate the tendon with no significant tension on the repair.
The secure repair was noted. The ends of the repair were further augmented with a 2-0 Vicryl suture. The wound was thoroughly irrigated with antibiotic irrigation solution. The fascial plane was closed with a 2-0 Vicryl suture, followed by closing the skin with a 2-0 in a subcuticular fashion. Approximately 10 ccs of 0.5% Marcaine was injected for postoperative pain control. A routine dressing was applied to the extremity, and it was placed into a short leg cast with the foot slightly plantar-flexed. The anterior aspect of the cast was then univalved. The tourniquet was deflated for a total tourniquet time of 42 minutes.
The patient was awakened in the operating room breathing spontaneously and taken to the recovery room in stable condition.

What are the CPT® and ICD-10-CM codes reported?

Answer 1

The CPT code for an open repair of a ruptured Achilles' tendon is likely 27650, and the ICD-10-CM code for a left Achilles' tendon rupture is S86.012A.

Step-by-step explanation:

The student is asking for the CPT (Current Procedural Terminology) and ICD-10-CM (International Classification of Diseases, Tenth Revision, Clinical Modification) codes for a surgical procedure of an open repair of a ruptured Achilles' tendon. For this scenario, the correct CPT code for the open repair of the Achilles' tendon is likely 27650 (Repair, primary, open or percutaneous, ruptured Achilles tendon). As for the diagnosis code, the appropriate ICD-10-CM code reflecting a left Achilles' tendon rupture is S86.012A (strain of left Achilles tendon, initial encounter). It's important that professionals who assign these codes check the latest coding manuals or online resources as codes can be updated.