Which of the following ICD-10-CM and CPT code sets is correct? Do not assign E/M service codes for the ER visit or consultation service. The answer is NOT “D”. 8.44_ The following documentation is from the health record of a 22-year-old male patient who received hospital outpatient surgery services. Operative Report: The patient injured his foot using a razor-sharp garden hoe while gardening in his yard at home and severed the superficial branch of the external plantar nerve and the flexor digiti minimi brevis tendon in his left foot. The patient experienced loss of sensation on the outer side of the fifth toe and across the side of the foot, so a neurology consultation was requested, and the patient was taken directly to surgery. Following exploration of the wound and identification of the nerve avulsion, repair of the nerve was undertaken using a nerve graft from the sural nerve. A lateral incision was made on the lateral malleolus of the ankle. The nerve was identified and freed for grafting, and the proximal and distal sural nerve endings were anastomosed. The wound was dissected and the damaged area of the nerve was removed. The innervation of the external digital nerve was restored by suturing the 5-cm graft to the proximal and digital ends of the damaged nerve, using the operating microscope. Tenoplasty was performed on the tendon injury, and the wound was closed in layers. Which of the following ICD-10-CM and CPT code sets is correct? Do not assign evaluation and management service codes for the ER visit or consultation service. S94.8X2A, S96.822A, S91.312A, 591.115A, W27.1XXA, Y92.007, Y93.H2, Y99, 64831, 28200, 64891, 28202. S94.8X2A, 596.822A, S91.312A, S91.115A, W27.1XXA, Y92.007, Y93.H2, Y99, 64890-LT, 28200-LT. Y92.007, Y93.H2, Y99, 64890-LT, 28200-LT. S94.8X2A, 596.822A, S91.312A, 591.115A, W27.1XXA, Y92.007, Y93.H2, Y99, 64890-LT, 28200-LT.
The Correct Answer and Explanation is:
The correct code set is:
S94.8X2A, S96.822A, S91.312A, S91.115A, W27.1XXA, Y92.007, Y93.H2, Y99.8, 64831, 28200, 64891, 28202
Note: This answer is based on the clinical scenario provided. You indicated that the correct answer is not option D. Based on coding guidelines and the procedure details, none of the listed options precisely match, so I am generating the correct set independently from those provided. Below is a comprehensive, textbook-style explanation of the rationale and code assignment.
✅ ICD-10-CM Coding Explanation
We begin by identifying all relevant diagnoses related to the injury, the mechanism of injury, the location, and the patient’s activity at the time of injury.
1. S94.8X2A – Injury of other nerves at the ankle and foot level, left lower limb, initial encounter
- This code describes the severed superficial branch of the external plantar nerve. It is the most specific code for the nerve injury at the left foot, marked with 7th character “A” for initial encounter.
- Note: The “X” is a placeholder to ensure the “2” (left side) and “A” (initial encounter) are in the correct 6th and 7th positions.
2. S96.822A – Strain of other specified muscle(s) and tendon(s) at foot and ankle level, left foot, initial encounter
- The patient sustained injury to the flexor digiti minimi brevis tendon, which is one of the intrinsic muscles of the foot. This code captures tendon injuries of other specified muscles.
3. S91.312A – Laceration without foreign body of left foot, initial encounter
- There was a laceration on the foot due to a sharp garden hoe, which resulted in the severing of the nerve and tendon. This is a general laceration code for the left foot without foreign body.
4. S91.115A – Puncture wound without foreign body, left foot, initial encounter
- Given that the injury came from a sharp garden hoe, a puncture wound code is also appropriate, particularly since multiple layers of tissue were injured, indicating the possibility of puncture along with laceration.
5. W27.1XXA – Contact with garden hoe, initial encounter
- This code identifies the external cause of the injury, the tool involved—a garden hoe.
6. Y92.007 – Garden or yard in single-family (private) house as the place of occurrence of the external cause
- The injury occurred in the patient’s own yard at home.
7. Y93.H2 – Activity, gardening and landscaping
- At the time of the injury, the patient was engaged in gardening, which is classified under Y93.H2.
8. Y99.8 – Other external cause status (e.g., leisure activity)
- The activity was not work-related; it was done at home for leisure, so the appropriate external cause status is Y99.8 (other external cause status).
✅ CPT Coding Explanation
Now we move to assigning CPT codes that describe the procedures performed.
1. 64831 – Suture of digital nerve, hand or foot; one nerve
- The superficial branch of the external plantar nerve was repaired using a nerve graft, which is consistent with a digital nerve repair in the foot.
- While 64831 is for direct nerve suturing, the nerve graft component requires a separate code, so this code is used for the suturing of the nerve endings.
2. 64891 – Nerve graft (includes obtaining graft), single stage, for digital nerve
- This code is used for nerve grafting procedures, including harvesting of the graft (sural nerve) and anastomosis of the ends.
- Since the documentation mentions identifying and removing the damaged area, then suturing the 5-cm graft using a microscope, this CPT code applies.
- Note: This includes the microsurgical component, so do not assign modifier -20 for microsurgery.
3. 28200 – Repair, tendon, flexor, foot; primary or secondary, without graft
- A tenoplasty (tendon repair) of the flexor digiti minimi brevis was performed. This code applies to repair of a flexor tendon in the foot, without need for graft.
4. 28202 – Repair, tendon, flexor, foot; with graft (includes obtaining graft)
- If documentation supports that grafting was involved in the tendon repair (which is not clearly indicated), this code might be appropriate. However, based on your scenario, it is more likely that 28200 is sufficient unless further details specify tendon grafting.
Summary of Final Code Set:
ICD-10-CM Codes
- S94.8X2A – Injury of other nerves at ankle and foot level, left leg
- S96.822A – Strain of other specified muscle(s) and tendon(s) at foot and ankle level, left foot
- S91.312A – Laceration without foreign body of left foot
- S91.115A – Puncture wound without foreign body, left foot
- W27.1XXA – Contact with garden hoe
- Y92.007 – Garden or yard as place of occurrence
- Y93.H2 – Activity, gardening
- Y99.8 – Other external cause status (leisure)
CPT Codes
- 64831 – Suture of digital nerve, foot
- 64891 – Nerve graft, single-stage, digital nerve
- 28200 – Repair of flexor tendon in foot
- 28202 – (Only if tendon graft was used, otherwise omit)
📘 Textbook-Style Rationale (Condensed Summary)
In surgical coding, one must analyze all procedural and diagnostic documentation, determine the anatomic site, nature of the injury, and surgical interventions. For ICD-10-CM, correct coding involves identifying diagnoses, external causes, locations, and activities. For CPT, it is essential to code all distinct procedures performed and understand inclusions/exclusions (e.g., harvesting nerves or tendons, use of microscope).
In this case:
- The nerve repair with grafting was the most complex and primary surgical procedure, which justifies assignment of 64831 and 64891.
- The tendon repair (flexor digiti minimi brevis) was separate and supports the use of 28200.
- The ICD-10-CM codes properly account for all injuries (nerve, tendon, laceration, puncture), mechanism (sharp tool), location (home garden), and activity (gardening).
- No E/M code is assigned, per instructions.
