ICD-10 Coding for Posterior Tibial Tendon Dysfunction(M76.821, M66.371, M21.41)
Complete ICD-10-CM coding and documentation guide for Posterior Tibial Tendon Dysfunction. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Posterior Tibial Tendon Dysfunction
M76.82-Primary Range
Other enthesopathy of ankle and foot
This range includes codes for posterior tibial tendon dysfunction, which is the primary condition being documented.
Spontaneous rupture of flexor tendons
Used for cases involving complete rupture of the posterior tibial tendon.
Flat foot [pes planus] (acquired)
Used to document acquired flatfoot deformity associated with PTTD.
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 for stage I or early stage II PTTD without complete rupture. |
|
| M66.371 | Spontaneous rupture of flexor tendons, right foot | Use when there is a confirmed complete rupture of the tendon. |
|
| M21.41 | Acquired flat foot, right foot | Use to document flatfoot deformity associated with PTTD. |
|
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 tendon dysfunction
Essential facts and insights about Posterior Tibial Tendon Dysfunction
Primary ICD-10-CM Codes for posterior tibial tendon dysfunction
Decision Criteria
clinical Criteria
- Presence of medial ankle pain and MRI findings of tenosynovitis.
Applicable To
- Posterior tibial tendon dysfunction, right
Excludes
- Rupture of posterior tibial tendon (M66.371)
Clinical Validation Requirements
- Pain and swelling along the medial ankle
- MRI showing tendon thickening or tenosynovitis
Code-Specific Risks
- Incorrectly coding for rupture when only tenosynovitis is present.
Coding Notes
- Ensure documentation specifies laterality and stage of dysfunction.
M66.371 - Spontaneous rupture of flexor tendons, right foot
Use when there is a confirmed complete rupture of the tendon.
Applicable To
- Complete rupture of posterior tibial tendon, right
Excludes
- Partial tear or tenosynovitis (M76.821)
Clinical Validation Requirements
- MRI confirming complete tendon discontinuity
- Inability to perform single-leg heel rise
Coding Notes
Ensure MRI findings are documented to support rupture diagnosis.
M21.41 - Acquired flat foot, right foot
Use to document flatfoot deformity associated with PTTD.
Applicable To
- Flatfoot deformity due to PTTD
Excludes
- Congenital flatfoot
Clinical Validation Requirements
- Weight-bearing X-ray showing decreased arch height
Coding Notes
Document the relationship between PTTD and flatfoot.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Acquired flat foot, right foot
M21.41Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting Posterior Tibial Tendon Dysfunction 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 treatment errors., Regulatory: Non-compliance with coding standards., Financial: Potential claim denials.
Mitigation Strategy
Always document the affected side., Use templates that prompt for laterality.
Impact
Reimbursement: Incorrect coding can lead to denied claims., Compliance: Non-compliance with coding guidelines., Data Quality: Impacts the accuracy of clinical data.
Mitigation Strategy
Specify the stage and laterality in documentation to select the correct code.
Impact
Failure to document the stage and laterality of PTTD.
Mitigation Strategy
Use detailed templates and checklists.
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 Tendon Dysfunction, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Posterior Tibial Tendon Dysfunction
Use these documentation templates to ensure complete and accurate documentation for Posterior Tibial Tendon Dysfunction. These templates include all required elements for proper coding and billing.
PTTD with flatfoot deformity
Specialty: OrthopedicsRequired Elements
- Patient history
- Physical exam findings
- Imaging results
- Treatment plan
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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