# Help With CPT coding of this Charcot foot procedure



## ELWOOD18 (Feb 26, 2015)

Dr #1: Procedure for Charcot foot: Revision? --LEFT FOOT, EXCISION CUBOID; 4TH & 5TH CALCANEO-METATARSAL ARTHRODESIS 
Post-Op Diagnosis Codes:
Arthropathy associated with neurological disorders [713.5]
Ulcer of heel and midfoot, unspecified laterality, limited to breakdown of skin [707.14]
ype II or unspecified type diabetes mellitus with neurological manifestations, not stated as uncontrolled [250.60] 
Unstable rocker-bottom foot deformity

Physician #2:  1st, 2nd and 3rd CALCANEO-METATARSAL ARTHRODESIS 
1.  Navicularectomy  left
2.  Lateral and medial cuneiformectomy      left 
3.  Talar medial cuneiform first metatarsal fusion/medial column fusion  left
4.  Tibialis anterior tendon advancement   left




PROCEDURE DETAILS: The risks and potential complications of their condition and purposed treatment include but are not limited to infection, nerve injury, vascular injury,  persistent pain, potential skin necrosis, deep vein thrombosis, possible pulmonary embolus, complications of the anesthetics and failure of the procedure.  The patient concurred with the proposed plan, giving informed consent.  The site of surgery properly noted/marked. The patient was taken to Operating Room identified as James Vincent Dececco and the procedure verified as Charcot foot reconstruction left. A 'Time Out' was held and the above information confirmed.




Following the successful induction of anesthesia the patient's left lower extremity was prepped and draped in the usual sterile fashion.  A well padded pneumatic tourniquet was placed about the patient's thigh.  The lower extremity was then elevated, exsanguinated and the tourniquet elevated. Attention was first directed to the medial aspect of the patient's foot where a curvilinear incision was made overlying the Metatarsal, extending proximally to the talus.  The incision was deepened using sharp and blunt dissection.  Incision was carried down to the level of the fascia.  At this point the tibialis anterior was encountered.  It was resected at its insertion onto the base of the metatarsal tagged and reflected.  This point a significant amount of scar tissue was appreciated throughout the midfoot.  The navicular was not appreciable at this time.  Upon further dissection inferior to the medial cuneiform, the navicular was appreciated inferior and lateral to the medial cuneiform.  It was also noted that the talus was grossly declination at an still anastomosing with the navicular.  Great care and time was taken to free the medial column of soft tissue adhesions and scarring.  The medial column was not reducible along the sagittal plane so at this point we elected to resect the navicular.  The navicular was freed of soft tissue attachments utilizing instrumentation inclusive of McGlamry elevator, the navicular was removed in toto.  It should be noted, that at the time of resection of the navicular, the posterior tibial tendon was not surgically identified and appeared to not be attached to the bone. At this point the intermediate and lateral cuneiforms were appreciated in the plantar space of the foot, disarticulated from both the navicular and metatarsal bases.  We elected to resect/remove these bones as well.  This obviously allowed us to mobilize the midfoot and medial rays.  There is still significant plantar prominence secondary to the grossly deformed cuboid and fracture dislocation of the fourth and fifth tarsometatarsal joints.  At this time a decision was made to resect the cuboid and prep the lateral column for fusion.  The details of this operative procedure can be found in Dr. David Goforth's operative report.  The tourniquet was deflated at the two-hour mark, essentially at the removal of the cuboid. 




Once the cuboid was removed significant preparation time was required at the base of the metatarsals secondary to the gross amount of scar tissue (~2 hours).   There is very limited range of motion of the rear foot inclusive of ankle range of motion.  Even with the tarsal bones resected, it was difficult to mobilize the rear foot.  Once the talar head, anterior calcaneus, and bases of the first through fifth metatarsals were prepped for fusion, a significant void was appreciated throughout the central columns and along the lateral column with approximation of the first ray.  Utilizing the cuboid, a 1 cm x 1.5 cm bone graft was utilized to account for this deficit.  Again, the details of which can be found in Dr. Goforth's operative report.  A single 10 cc Osteoamp sponge as well as 10 cc of Osteoamp chips as well as the ground up bone that was removed from the patient's foot was prepped to accommodate the fusion sites and voids.Once the deficits were packed with biologic product and bone chips, a guidewire for a 4.5 titanium screw was passed across the medial cuneiform into the talus.  This was done under fluoroscopy.  The forefoot was positioned slightly plantar flexed to the ankle and in alignment with the talus.  Utilizing standard AO fixation technique the 4.5 screw was passed across the navicular into the talus.  A second screw was inserted through the lateral aspect of the fifth metatarsal/styloid process into the calcaneus.  Several images were taken with fluoroscopy to evaluate for anatomical alignment and positioning of the orthopedic hardware.




A Charcot foot reconstruction plate was taken from the right medical tray for fusion and fixation of the medial column.  This plate was tagged into place overlying the medial talus, medial cuneiform and first metatarsal.  Using a combination of locking 4.5 screws and 4.5 cortical screws, the plate was secured to the medial column.  A remainder bone chips and biologic product were utilized to pack around the bony deficits along the first ray.


----------



## ELWOOD18 (Mar 5, 2015)

*Unlilsted code??*

28730
28122
or   28999

Which codes would you use for the Posted scenario?

Thanks.


----------

