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
Injury of peroneal tendon
Covers tears and other injuries to peroneal tendons.
Other enthesopathies
May include peroneal tendon tear if enthesopathy is present.
Sprain and strain of ankle and foot
May be used for less severe peroneal tendon strains.
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?
When to use each related code
Description |
---|
Peroneal tendon tear |
Ankle sprain |
Lateral ankle impingement |
Coding peroneal tendon tear without specifying left, right, or bilateral can lead to claim denials and inaccurate data reporting.
Failing to document partial vs. full-thickness tear impacts accurate code assignment and reimbursement for peroneal tendon repair.
Overlooking related diagnoses like ankle instability or tendon subluxation can affect DRG assignment and quality metrics.
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.