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S86.319A
ICD-10-CM
Peroneal Tendon Tear

Find information on peroneal tendon tear diagnosis, including clinical documentation, ICD-10 codes (S66.8, M76.9), CPT codes for procedures like tenography (76998) and surgical repair (27698, 27695), and healthcare resources. Learn about peroneal tendon subluxation, peroneal tendonitis, and peroneal retinaculum tears. Explore relevant medical coding guidelines and accurate documentation requirements for peroneal tendon injuries. Research symptoms, treatment options, and rehabilitation protocols related to peroneal tendon tears.

Also known as

Peroneal Tendon Rupture
Peroneal Tendon Injury

Diagnosis Snapshot

Key Facts
  • Definition : Tear of tendons stabilizing the outer ankle, causing pain and instability.
  • Clinical Signs : Lateral ankle pain, swelling, popping sensation, difficulty with eversion, ankle instability.
  • Common Settings : Sports injuries, ankle sprains, overuse, flat feet, high arches.

Related ICD-10 Code Ranges

Complete code families applicable to AAPC S86.319A Coding
S96.7-

Injury of peroneal tendon

Covers tears and other injuries to peroneal tendons.

M76.8-

Other enthesopathies

May include peroneal tendon tear if enthesopathy is present.

S93.4-

Sprain and strain of ankle and foot

May be used for less severe peroneal tendon strains.

Code-Specific Guidance

Decision Tree for

Follow this step-by-step guide to choose the correct ICD-10 code.

Is the peroneal tendon tear traumatic?

  • Yes

    Which tendon is torn?

  • No

    Is it chronic/degenerative?

Code Comparison

Related Codes Comparison

When to use each related code

Description
Peroneal tendon tear
Ankle sprain
Lateral ankle impingement

Documentation Best Practices

Documentation Checklist
  • Peroneal tendon tear diagnosis documentation:
  • Laterality (left or right)
  • Specific tendon involved (peroneus longus, brevis, or both)
  • Tear location and extent (partial or complete)
  • Mechanism of injury (traumatic or degenerative)
  • Physical exam findings (pain, swelling, instability)

Coding and Audit Risks

Common Risks
  • Unspecified Laterality

    Coding peroneal tendon tear without specifying left, right, or bilateral can lead to claim denials and inaccurate data reporting.

  • Missing Tear Severity

    Failing to document partial vs. full-thickness tear impacts accurate code assignment and reimbursement for peroneal tendon repair.

  • Associated Conditions

    Overlooking related diagnoses like ankle instability or tendon subluxation can affect DRG assignment and quality metrics.

Mitigation Tips

Best Practices
  • Document lateral ankle pain, swelling, instability for accurate ICD-10 coding (S66.87, M62.87).
  • CDI: Specify partial vs full tear, peroneus longus vs brevis, acute vs chronic for CPT coding (27690-27692).
  • Image with MRI or ultrasound. Thoroughly document findings for compliance and payer reimbursement.
  • Assess for subluxation/dislocation. Include details for proper procedure coding (27695-27698, 27840-27842).
  • Conservative Rx: Document bracing, PT, NSAIDs. Surgical Rx: Detailed op note improves compliance.

Clinical Decision Support

Checklist
  • 1. Lateral ankle pain ICD-10: M76.87, S93.401
  • 2. Subfibular tenderness/swelling SNOMED CT: 307863005
  • 3. Positive peroneal snap test ICD-10: M24.47
  • 4. Pain with eversion/resisted dorsiflexion

Reimbursement and Quality Metrics

Impact Summary
  • Peroneal Tendon Tear reimbursement hinges on accurate CPT coding (27670, 27675) and ICD-10 (S96.001A, S96.009A) for optimal claims processing and reduced denials. Proper modifier use (e.g., -LT, -RT) impacts payment.
  • Quality metrics for Peroneal Tendon Tear repair involve tracking surgical site infection rates (SSI), return to function timelines, and patient-reported outcome measures (PROMs). Accurate documentation is crucial.
  • Timely claim filing and correct coding of associated diagnoses (e.g., ankle instability, chronic pain) maximize Peroneal Tendon Tear reimbursement and reflect resource utilization.
  • Optimize Peroneal Tendon Tear revenue cycle management through detailed documentation, specific laterality coding, and accurate reporting of complications for accurate reimbursement and quality data.

Streamline Your Medical Coding

Let S10.AI help you select the most accurate ICD-10 codes. Our AI-powered assistant ensures compliance and reduces coding errors.

Quick Tips

Practical Coding Tips
  • Code tear location: peroneus longus/brevis
  • ICD-10 S96.8xxA, M76.9
  • MRI confirms diagnosis, code findings
  • Document mechanism of injury
  • Surgical repair: add CPT code 27698

Documentation Templates

Patient presents with complaints consistent with peroneal tendon tear symptoms, including lateral ankle pain, swelling, instability, and difficulty with eversion.  Onset of symptoms began (date of onset) following (mechanism of injury - e.g., inversion ankle sprain, repetitive overuse).  Patient reports (presence or absence of) popping or snapping sensation at the time of injury.  Physical examination reveals (tendernesslocation - e.g., posterior to the lateral malleolus),  (edema presence and extent),  and (ecchymosis presence and extent).  Pain is exacerbated with (movements - e.g., resisted eversion, passive inversion).  Subluxation or dislocation of the peroneal tendons (was or was not) observed.  Differential diagnosis includes lateral ankle sprain, peroneal tendonitis, cuboid syndrome, and stress fracture of the fifth metatarsal.  Diagnostic imaging, including (X-ray, MRI, or ultrasound findings - e.g.,  ankle X-ray negative for fracture; MRI reveals longitudinal split tear of the peroneus brevis tendon), was performed to confirm the diagnosis and evaluate the extent of the tear.  Assessment: Peroneal tendon tear (specify brevis, longus, or both).  Plan:  Conservative treatment will be initiated, including rest, ice, compression, elevation (RICE), non-steroidal anti-inflammatory drugs (NSAIDs), and immobilization with a walking boot or cast for (duration).  Physical therapy will be prescribed to address range of motion, strength, and proprioception deficits.  Surgical intervention (will or will not) be considered if conservative management fails to provide adequate relief.  Patient education regarding activity modification and rehabilitation was provided.  Follow-up appointment scheduled in (timeframe) to reassess symptoms and progress.
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