Question

OPERATIVE REPORT

Preoperative Diagnosis : Plantar fasciitis, left

Postoperative Diagnosis : Same as the preoperative diagnosis.

Procedures : Plantar fasciotomy, left heel.

For informed consent, the more common risks, benefits, and alternatives to the procedure were thoroughly discussed with the patient. An appropriate consent form was signed, indicating the patient understands the procedure and its possible complications.
This 61-year-old male was brought to the operating room and placed on the surgical table in a supine position. Following anaesthesia, the surgical site was prepped and draped in the normal sterile fashion. Attention was directed to the left heel where - utilizing a 61 blade - a stab incision was made, taking care to identify and retract all vital structures. The incision was deepened to the medial band insertion of the fascia. The fascia was then incised and avulsed from the calcaneus. The surgical site was flushed with saline. Next, 1 cc of Depo-Medrol was injected in the operative site. The site was dressed with a light compressive dressing. Excellent capillary refill to all of the digits was observed without excessive bleeding noted.

Hemostasis : None.

Estimated Blood Loss : Minimal.

Injectables : Agent used for local anaesthesia was 5.0 cc Marcaine 0.5% with epinephrine.

Pathology : No specimen sent.

Dressings : Applied Bacitracin ointment. The site was dressed with a light compressive dressing.

Condition : Patient tolerated the procedure and anaesthesia well. Vital signs were stable. Vascular status was intact to all digits. The patient recovered in the operating room.

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

Answer 1

The CPT code for the plantar fasciotomy procedure is 28002, and the ICD-10-CM diagnosis code for plantar fasciitis is M72.2.

Step-by-step explanation:

The operative report provided outlines a procedure conducted for the treatment of plantar fasciitis. For coding purposes, according to the American Medical Association, the Current Procedural Terminology (CPT) code for a plantar fasciotomy is 28060 when it is related to the excision of plantar fibromatosis. In this case, since a fasciotomy was performed specifically, we would look for a code that accurately reflects this procedure. An appropriate code might be 28002, which is for the open treatment of plantar fasciitis with plantar fasciotomy.

As for the diagnosis code, the International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) code for plantar fasciitis is M72.2, specifically indicating fibroblastic disorder which correlates with plantar fasciitis.

Therefore, the CPT code reported for the procedure would be 28002, and the ICD-10-CM code for the diagnosis would be M72.2.