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Z98.1
ICD-10-CM
Subtalar Fusion

Find comprehensive information on Subtalar Fusion, including clinical documentation requirements, ICD-10 and CPT codes for medical billing, postoperative care guidelines, and relevant healthcare resources. Learn about diagnosis criteria, surgical techniques, and complications associated with Subtalar Arthrodesis. This resource is designed for medical professionals seeking accurate and up-to-date information on Subtalar Joint Fusion.

Also known as

Subtalar Arthrodesis
Tarsal Joint Fusion

Diagnosis Snapshot

Key Facts
  • Definition : Surgical fusion of the subtalar joint to eliminate motion and relieve pain.
  • Clinical Signs : Arthritis, instability, flatfoot deformity, pain with walking, limited range of motion.
  • Common Settings : Trauma centers, orthopedic clinics, hospitals, ambulatory surgery centers.

Related ICD-10 Code Ranges

Complete code families applicable to AAPC Z98.1 Coding
M96-M99

Other biomechanical lesions

Covers other specified biomechanical lesions not classified elsewhere.

M70-M79

Soft tissue disorders

Includes disorders of muscles, tendons, synovia, and bursae.

M00-M99

Diseases of the musculoskeletal system and connective tissue

Encompasses various musculoskeletal and connective tissue diseases.

Code-Specific Guidance

Decision Tree for

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

Is the subtalar fusion performed for a specific condition?

  • Yes

    Is it due to arthritis?

  • No

    Is it for stabilization/arthrodesis?

Code Comparison

Related Codes Comparison

When to use each related code

Description
Subtalar Fusion
Calcaneal Fracture
Talar Fracture

Documentation Best Practices

Documentation Checklist
  • Subtalar fusion diagnosis code
  • Document laterality (left or right)
  • Underlying condition causing fusion need
  • Date of onset or injury date
  • Imaging evidence supporting diagnosis

Coding and Audit Risks

Common Risks
  • Unspecified laterality

    Coding and documentation must specify left, right, or bilateral subtalar fusion for accurate reimbursement.

  • Inaccurate approach code

    Open, percutaneous, or arthroscopic approach must be correctly coded with the primary fusion code to reflect complexity.

  • Missing bone graft code

    If a bone graft is used, it should be coded separately. Documentation should support the use of bone graft.

Mitigation Tips

Best Practices
  • Document subtalar instability, arthritis, deformity for accurate ICD-10-CM coding (M19.07x, M19.01x).
  • Specific laterality (right, left, bilateral) required for CPT 28725, 28730. CDI crucial.
  • Query physician for cause of subtalar pathology (trauma, inflammatory). Impacts coding, compliance.
  • Ensure pre-op imaging confirms diagnosis and supports medical necessity for optimal reimbursement.
  • Post-op documentation must reflect fusion method, implants used. HCC coding implications.

Clinical Decision Support

Checklist
  • Verify subtalar instability diagnosis: imaging, exam findings
  • Confirm failed conservative treatment: bracing, orthotics, PT
  • Assess arthritis severity: X-rays, patient reported pain
  • Evaluate for hindfoot deformity: varus/valgus, flexibility
  • Screen for contraindications: infection, neuropathy, AVN

Reimbursement and Quality Metrics

Impact Summary
  • Subtalar Fusion Reimbursement: CPT 28730, 28735 impact payment. ICD-10 coding (e.g., S96.0) accuracy crucial for maximizing revenue.
  • Quality Metrics Impact: Post-op complications (e.g., wound infection) affect hospital value-based purchasing scores. Accurate surgical documentation key.
  • Coding Accuracy: Precise coding of arthrodesis, bone graft, and hardware impacts DRG assignment and hospital reimbursement.
  • Hospital Reporting: Subtalar fusion data reporting impacts quality improvement initiatives. Accurate coding & documentation essential for analysis.

Streamline Your Medical Coding

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

Quick Tips

Practical Coding Tips
  • ICD-10-PCS 0QBN0JZ fusion
  • CPT 28725 for arthrodesis
  • Document joint location, laterality
  • Include cause for fusion, e.g., arthritis
  • Confirm bone graft use, if any

Documentation Templates

Subtalar fusion surgical procedure was performed to address the patient's subtalar joint pain and dysfunction.  The patient presented with chronic subtalar instability, hindfoot arthritis, pes planus deformity, and significant limitations in activities of daily living.  Conservative treatment options, including orthotics, physical therapy, and nonsteroidal anti-inflammatory drugs NSAIDs, failed to provide adequate relief.  Diagnostic imaging, including weight-bearing X-rays and potentially a CT scan or MRI, confirmed the diagnosis of subtalar joint degeneration and ruled out other conditions such as calcaneal fractures, tarsal coalition, or posterior tibial tendon dysfunction.  Preoperative evaluation included a thorough assessment of the patient's medical history, including any comorbidities such as diabetes or peripheral vascular disease, which could impact surgical outcome.  The surgical procedure involved arthrodesis of the subtalar joint, utilizing either internal fixation with screws or plates, or a combination of both, to achieve stability and pain relief.  Bone grafting may have been necessary to promote fusion.  Postoperatively, the patient's foot was immobilized in a cast or splint.  The patient will require ongoing monitoring for complications such as nonunion, infection, or nerve damage.  Postoperative care will include pain management, physical therapy, and gradual weight-bearing progression as tolerated.  Follow-up appointments will be scheduled to assess the fusion progress, evaluate range of motion, and address any postoperative complications.  ICD-10 code M96.70, Subtalar instability, and CPT codes 28725, Arthrodesis subtalar joint, extra-articular or combined extra-articular and intra-articular, and 27690-27692 if bone grafting was performed, are relevant to this surgical intervention. The prognosis for pain relief and improved functional outcomes following subtalar fusion is generally good.