A patient with a diagnosis of painful orthopedic hardware and posterior tibial tendon adhesions was seen at our facility to undergo an ankle arthroscopy with debridement, removal of hardware and a posterior tibial tendoscopy with tenolysis. The tendolysis was performed following the ankle debridement and removal of the hardware via an extended incision which opened the fascia over the tendon. A scope was inserted into the tendon sheath and a shaver was used to remove synovitis and superficial tears of the tendon.
What are the appropriate codes for the procedures performed?
Based on the operative report submitted, report CPT code 29898, Arthroscopy, ankle (tibiotalar and fibulotalar joints), surgical; debridement, extensive, for the procedures performed. The tendoscopy with the tenolysis would be captured in the CPT code for the debridement and not separately reported. CPT code 20680, Removal of implant; deep (e.g., buried wire, pin, screw, metal band, nail, rod or plate), would be reported for removal of the hardware.