# 1st Metatarsal Phalangeal Joint Arthrodesis Reversal and Total Joint Arthroplasty



## MI_CODER (Dec 28, 2017)

How would you code the following:

Procedure(s):
Removal Hardware 1st Metatarsal Phalangeal Joint with Reversal of Arthrodesis with Total Joint Implant Arthroplasty 1st Metatarsal Phalangeal Joint

Post-operative Diagnosis:
Arthrodesis malunion (M96.0)
Right foot pain
Arthritis right foot

Attention was directed to the right foot where prior incisions were noted medially along the 1st metatarsophalangeal joint  and dorsally along the 1st interspace. A dorsal medial incision was made. Sharp and blunt dissection were carried down to the deeper tissue planes. Capsular incision was made. The extensor tendon was intact, which was retracted laterally. There was a 6-hole tubular plate with 6-screw fixation present along with 2 cross screws obliquely across the 1st metatarsophalangeal joint; these were all removed. The joint level was identified with mini fluoroscopy. The arthrodesis was transected with a sagittal saw. Next, using Arthrosurface, total joint implant technique, the joint surfaces were prepared and reamed according to manufacturer recommendations. A 9.5 mm tapered post was inserted in the 1st metatarsal. First metatarsal head component with a dorsal flange was inserted following various trials. The phalangeal component was also inserted at this time with a 4 mm poly implant. Good approximation, position and alignment was present at this time. There was good motion on the table, there was no impingement. The joint did appear somewhat unstable due to prior removal of the sesamoids. The area was copiously irrigated. Capsular repair was performed with 2-0 Vicryl suture. Subcuticular closure was performed with 4-0 Vicryl suture. Skin closure was performed with a 4-0 nylon in a running subcuticular suture fashion.

So far I've come up with 20680 and 28322. I'm not 100% sure that 28322 is the correct code but I don't know what else to use. I also can't find a code for the 1st metatarsophalangeal joint arthroplasty.

Thank you in advance.


----------



## moconn (Dec 28, 2017)

what about 26531??


----------



## MI_CODER (Dec 29, 2017)

Thanks for your response but 26531 is for the metacarpophalangeal joint. I need a code for the metatarsophalangeal joint.


----------



## hblakeman (Dec 29, 2017)

*28291 or 28899*

The implant manufacturer we use has directed us to use 28291, which is a new code for 2017.  The code is specifically for Hallux Rigidus which is an arthritic condition, so it may work for yours.


----------



## MI_CODER (Dec 30, 2017)

I'm not sure about using 28291 because my provider isn't correcting a hallux rigidus. He originally repaired a hallux valgus with the arthrodesis which went on to malunion. He's now converting the arthrodesis into an arthroplasty.

I'm thinking that I'm just going to have to use an unlisted code (28899). After doing research, I don't think I can code 20680 as the hardware removal would be included in the arthrodesis reversal and arthroplasty. I don't feel that 28322 would be appropriate to code because the description for this code says the malunion is repaired with a pin. My provider isn't repairing the malunion with a pin; he's converting the arthrodesis into an arthroplasty. I can't find any other code that would fit this description so I'm thinking an unlisted code is my only option.


----------



## AlanPechacek (Jan 10, 2018)

For the most part your analysis is correct.  There is/are no code(s) that would cover this particular situation.  I would recommend the *Unlisted Procedure* code *28899* with *Modifier* *22* for *Increased Procedural Service* for all the work required to convert the Arthrodesis to an MP Joint Arthroplasty.  I would "pair" it with *28291* as that is the only code that fits the "concept" of an MP Joint Arthroplasty with Implant.  I would also list the *20680* for *Removal of Deep/Buried Fixation* since I doubt it is "bundled" with 28899, and he couldn't have done this procedure without removing the fixation.  He did a lot of work and that needs to be acknowledged/reflected by the coding.  Send the Operative Report as well.

Respectfully submitted, Alan Pechacek, M.D.


----------

