Spontaneous rupture of extensor tendons, right lower leg

This code signifies a non-traumatic tear of the extensor tendons located in the right lower leg. This rupture occurs without an external force or injury, often due to underlying degenerative changes or inflammatory processes within the tendon itself. It results in impaired ability to dorsiflex the foot or toes on the affected side.

Apply this code when documentation clearly indicates a spontaneous (non-traumatic) rupture of an extensor tendon in the patient's right lower leg. This typically involves a sudden onset of pain, swelling, and functional deficit in the absence of an acute injury. Physician notes detailing the mechanism of injury as non-traumatic and specifying the right lower leg extensor tendons are crucial.

• Ensure the documentation explicitly states "spontaneous" or "non-traumatic" to differentiate from traumatic ruptures.
• Verify the laterality (right lower leg) is clearly documented; separate codes exist for the left or unspecified leg.
• Distinguish from other tendon disorders like tendinitis or tenosynovitis, which do not involve a complete rupture.