ICD-10 Coding for Posterior Tibial Tendinitis(M76.821, M76.822, M76.829, M66.37)
Complete ICD-10-CM coding and documentation guide for Posterior Tibial Tendinitis. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Posterior Tibial Tendinitis
M76.82-M76.829Primary Range
Other enthesopathy of ankle and foot
This range includes codes for posterior tibial tendinitis with specification for laterality.
Spontaneous rupture of other tendons, ankle and foot
Used when there is a tendon rupture associated with posterior tibial tendinitis.
Flat foot [pes planus] (acquired)
Used when posterior tibial tendinitis is associated with acquired flatfoot deformity.
Code Comparison: When to Use Each Code
Compare key differences between these codes to ensure accurate selection
| Code | Description | When to Use | Key Documentation |
|---|---|---|---|
| M76.821 | Other enthesopathy of right foot | Use when the patient has posterior tibial tendinitis affecting the right foot. |
|
| M76.822 | Other enthesopathy of left foot | Use when the patient has posterior tibial tendinitis affecting the left foot. |
|
| M76.829 | Other enthesopathy of unspecified foot | Use only when laterality cannot be determined after thorough examination and imaging. |
|
| M66.37 | Spontaneous rupture of other tendons, ankle and foot | Use when there is a confirmed rupture of the posterior tibial tendon. |
|
Clinical Decision Support
Always review the patient's clinical documentation thoroughly. When in doubt, choose the more specific code and ensure documentation supports it.
Key Information: ICD-10 code for posterior tibial tendinitis
Essential facts and insights about Posterior Tibial Tendinitis
Primary ICD-10-CM Codes for posterior tibial tendinitis
Decision Criteria
clinical Criteria
- Presence of medial ankle pain and imaging confirmation
Applicable To
- Right posterior tibial tendinitis
Excludes
- Tendon rupture (M66.37)
Clinical Validation Requirements
- Pain and swelling along the medial ankle
- Positive single-leg heel raise test
- Ultrasound or MRI confirming tendinitis
Code-Specific Risks
- Confusion with tendon rupture codes
Coding Notes
- Ensure laterality is documented; avoid using unspecified codes unless necessary.
M76.822 - Other enthesopathy of left foot
Use when the patient has posterior tibial tendinitis affecting the left foot.
Applicable To
- Left posterior tibial tendinitis
Excludes
- Tendon rupture (M66.37)
Clinical Validation Requirements
- Tenderness distal to medial malleolus
- MRI showing tendon thickening
- Inability to perform single-leg heel raise
Coding Notes
Document the stage of tendinitis if applicable.
M76.829 - Other enthesopathy of unspecified foot
Use only when laterality cannot be determined after thorough examination and imaging.
Applicable To
- Unspecified laterality for posterior tibial tendinitis
Excludes
- Tendon rupture (M66.37)
Clinical Validation Requirements
- Generalized pain without specific laterality
- Imaging not specifying laterality
Coding Notes
Avoid using this code if laterality can be determined.
M66.37 - Spontaneous rupture of other tendons, ankle and foot
Use when there is a confirmed rupture of the posterior tibial tendon.
Applicable To
- Rupture of posterior tibial tendon
Excludes
- Non-rupture tendinitis (M76.82-)
Clinical Validation Requirements
- MRI showing tendon discontinuity
- Surgical confirmation of rupture
Coding Notes
Ensure rupture is confirmed through imaging or surgery.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Differential Codes
Alternative codes to consider when ruling out similar conditions to the primary diagnosis.
Anterior tibial syndrome
M76.81-Tarsal tunnel syndrome
G57.5-Achilles tendon injury
S86.09-Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting Posterior Tibial Tendinitis to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code M76.821.
Impact
Clinical: Leads to less precise treatment plans., Regulatory: Non-compliance with coding standards., Financial: Potential for claim denials or reduced reimbursement.
Mitigation Strategy
Review documentation for laterality before coding., Educate staff on the importance of specifying laterality.
Impact
Reimbursement: Incorrect coding can lead to denied claims or incorrect DRG assignment., Compliance: Misclassification may result in audit findings., Data Quality: Affects the accuracy of clinical data and patient records.
Mitigation Strategy
Use M66.37 for confirmed ruptures and M76.82- for tendinitis.
Impact
Reimbursement: Claims may be denied due to lack of specificity., Compliance: Non-compliance with ICD-10 coding guidelines., Data Quality: Leads to incomplete patient records.
Mitigation Strategy
Always specify right, left, or unspecified in documentation.
Impact
Frequent use of unspecified codes can trigger audits.
Mitigation Strategy
Ensure thorough documentation of laterality and specific findings.
Documentation errors, coding pitfalls, and audit risks are interconnected aspects of medical coding and billing. Addressing all three areas helps ensure accurate coding, optimal reimbursement, and regulatory compliance.
Frequently Asked Questions
Common questions about ICD-10 coding for Posterior Tibial Tendinitis, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Posterior Tibial Tendinitis
Use these documentation templates to ensure complete and accurate documentation for Posterior Tibial Tendinitis. These templates include all required elements for proper coding and billing.
Initial evaluation of posterior tibial tendinitis
Specialty: PodiatryRequired Elements
- Patient history
- Physical examination findings
- Imaging results
- Functional limitations
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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