# arthroplasty on a fractured toe?



## laurabee (Jun 18, 2009)

I'm coding for ASC's and a podiatrist just started working there-- I have ortho experience but no experience with podiatry, and I am stumped on this one. The doctor says he performed an arthroplasty, but I'm not finding the correct code for what he did. Any help is appreciated!! Here is the op note:

PREOPERATIVE DIAGNOSIS:	Painful fracture at the proximal phalangeal joint second digit, left foot.

POSTOPERATIVE DIAGNOSIS:	Painful fracture at the proximal phalangeal joint second digit, left foot.

PROCEDURE PERFORMED:	Arthoplasty proximal phalangeal joint second digit, left foot.


ANESTHESIA:	IV sedation with a local block utilizing 1:1 mixture of 1% lidocaine plain and 0.5% Marcaine plain for a total of 13 cc.

ANESTHESIOLOGIST:	

PATHOLOGY:	There was no pathology.

HEMOSTASIS:	Ankle tourniquet raised at 250 mmHg for a total of 12 minutes.

ESTIMATED BLOOD LOSS:	Less than 5 cc.

MATERIAL USED:	4-0 Vicryl and a 4-0 Prolene suture.

INJECTABLES:	5 cc for 0.5% Marcaine plain.

SIGNIFICANT FINDINGS:  There was increase hypertrophic scar tissue at the level of the head of the proximal phalanx.  Once dissected to the head, it was noted to have denuded cartilage or linear cartilage denuded along the central aspect of the proximal phalanx.  This was possibly the aspect of a nonhealing fracture.  Once the proximal phalangeal head was resected, the proximal bone was intact with no signs of fracture noted.

DESCRIPTION OF PROCEDURE:  The patient was taken to the operating room, placed on the operating table in the supine position.  IV sedation was administered followed by local block.  The foot was then prepped and draped in the usual aseptic manner.  Ankle tourniquet was applied.  The foot was elevated.  An Esmarch was used for exsanguination of blood.  All procedures were performed.

PROCEDURE #1:  Arthoplasty second digit and proximal phalangeal joint, left foot.

We first made a dorsolinear incision over the proximal phalangeal joint.  Once down to the capsule and extensor tendon, a transverse tenotomy was performed at the proximal phalangeal joint.  The extensor tendon was resected approximally and the mediolateral and plantar collateral ligament of the proximal phalangeal joint were resected.  At this time, we were able to visualize the head of the proximal phalanx giving dissection down to the head.  It was noted that there was increased scar tissue over the head of the proximal phalanx.  This was probably due to fracture of the proximal phalanx itself.  Once we got down to that area, we were able to visualize the head and noted that there another cartilage in the linear stage allowing dorsal plantar of the proximal phalanx head distally.  At the level of the fracture site, the bone itself was stable at this level.  Next, we utilized a saw and excised the head of the proximal and removing it from the filed.  The proximal bone was tested and noted to be stable and no signs of fracture.  The area was thoroughly irrigated at this time followed by reapproximation of extensor tendon with the 4-0 Vicryl and reapproximation of the skin with 4-0 Prolene suture.  The patient tolerated the procedure and anesthesia well, and left the operating room neurovascular status and vital signs stable.  Dressings included Xeroform, 4x4s, Kling, and Ace bandage.  She will follow up in the clinic in two days for dressing change.  She will be instructed to be weightbearing with the surgical shoe, decrease activity, and we have given pain medication.


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## martnel (Jul 7, 2009)

I am looking at 28525, but it does not specificaly include any bonecutting/sawing?  What about 28312?  That, on the other end, does not cross reference  with a fx dx ?  Now I want to know too!  LOL!


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## ebarnett (Jul 21, 2009)

*arthroplasty toe*

I don't think you want to use 28312 because is specifically talks about putting in a screw.  

Look at 28150.


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## mbort (Jul 23, 2009)

28285


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## carrieestes (Jul 31, 2009)

*CPT Code: 28124*

Partial excision (craterization, saucerization, sequestrectomy, or diaphysectomy) bone (eg, osteomyelitis or bossing); phalanx of toe

Intraoperative services included in the global service package, when indicated:

1.local infiltration of medication(s), anesthetic or contrast agent before, during, or at the conclusion of the operation (eg, 11900, 11901, 15860, 20500, 20501, 76080, 90765-90779)
2.suture or staple removal by operating surgeon or designee (eg, 15850, 15851)
3.surgical approach, with necessary identification, isolation, and protection of anatomical structures, including hemostasis and minor skin scar revision
4.obtaining wound specimen(s) for culture
5.wound irrigation
6.intraoperative photo(s) and/or video recording, excluding ionizing radiation
7.intraoperative supervision and positioning of imaging and/or monitoring equipment by operating surgeon or assistant(s)
8.insertion, placement, and removal of surgical drain(s), re-infusion device(s), irrigation tube(s), or catheter(s)
9.closure of wound and repair of tissues divided for initial surgical exposure, partial or complete (eg, 12001-12057)
10.application of initial dressing, orthosis, continuous passive motion, splint or cast, including traction, except where specifically excluded from global package 
11.preparation and insertion of synthetic bone substitutes, osteoconductive and osteoinductive agents (eg, hydroxyapatite, calcium phosphates, coral, methylmethacrylate, demineralized bone matrix, bone morphogenetic proteins),  except where specifically excluded 
12.arthrotomy (eg, 28022, 28024)
13.tenotomy, extensor (eg, 28234)
14.synovectomy interphalangeal joint
15.capsulotomy for joint contracture, interphalangeal joint (eg, 28272)
16.synovial biopsy, interphalangeal joint (eg, 28054)
17.excision of skin lesion (eg, 11420-11426, 28043)
18.tenolysis and/or tenosynovectomy (eg, 28086-28088, 28220-28226)

Intraoperative services not included in the global service package, when indicated

1.supplies and medication (eg, codes 99070, HCPCS Level II codes)
2.complex wound closure (eg, application of wound vacuum device to open wound, (eg, 97605-97606)) or closure requiring local or distant flap coverage and/or skin graft, when appropriate (eg, 13100-13160, 14000-14350, 15000-15400, 15570-15776)
3.insertion, removal, or exchange of nonbiodegradable drug delivery implants (eg, 11981-11983)
4.syndactylization (eg, 28280)

Medicare global fee period: 090 days
_________________________________________________________________

*Dx: 905.4  -> Late effect of fracture of lower extremities*


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