# Lapidus vs Metatarsal-Cuneiform Fusion with Bunionectomy



## anwalden (Mar 12, 2012)

*Ok, I need some opinions on how we should be coding this procedure. Our podiatrist schedules these procedures with CPTs 28740, 28290, 20902. I'm concerned that the true intent is simply to correct the bunion, which would make the procedure a 28297. I've copied an example of one of his Op Notes below. Any input is greatly appreciated!*




PREOPERATIVE DIAGNOSES:  	1.	Gastroc equinus.  
	2.	Hypermobility and hyperpronation in the medial column of the left foot and distal bunion.  

POSTOPERATIVE DIAGNOSES:  	1.	Gastroc equinus.  
	2.	Hypermobility and hyperpronation in the medial column of the left foot and distal bunion.  

PROCEDURE PERFORMED:  	1.	Gastroc recession.  
	2.	Deep distal tibial bone graft.  
	3.	Arthrodesis of the medial column for correction of the hyperpronation and instability of medial column and correction of distal bunion.  

PATHOLOGY:  	None.  

ANESTHESIA:  	LMA.  

HEMOSTASIS:  	Pneumatic calf tourniquet at 200 mmHg for 51 minutes.  

ESTIMATED BLOOD LOSS:  	Minimal.  

COMPLICATIONS:  	None.  

CONDITION:  	Condition of the patient is stable.  

DESCRIPTION OF PROCEDURE:  The patient was transferred from the preoperative holding area to the operating room.  The patient was placed on the table in the supine position.  A time-out was performed by indicating appropriate extremity, which was marked, confirmed in the consent by anesthesia, operating room staff, and myself.  Anesthesia supplied appropriate antibiotics at appropriate time.  The limb was elevated on Mayo stand.  Attention was then directed to the medial aspect of the distal calf muscle belly in left side where a linear incision was made.  This was carried down bluntly over the peritenon.  The peritenon was incised and the gastroc fibers were isolated from the soleal fibers and transverse transection was performed with Metzenbaum scissors.  The wounds were irrigated with copious amount of sterile saline.  No residual gastroc equinus was remained.  
The peritenon was closed with Vicryl, subcu Vicryl, and the skin with 3-0 nylon.  It should be noted all incisions were closed in the exact same manner.  Attention was then directed to the distal anterior medial aspect of the distal tibia where a linear incision was made medial to the anterior tibialis tendon.  This was carried down to bone.  The periosteum was then reflected and a cortical window was made with the periosteotome and mallet.  This window was opened and deep medullary bone was curetted from the tibia and passed into specimen cup.  This was passed from the surgical field.  The wound was irrigated with copious amounts of sterile saline.  The cortical window was then replaced and all the tissues were closed in the exact same manner.  Attention was then directed to the dorsal aspect of the first metatarsocuneiform joint where a linear incision was made medial and parallel to the extensor hallucis longus tendon.  Soft tissue dissection was carried down with a #15 blade.  Care was taken as to retract all neurovascular and vital structures.  The soft tissue was then freed off the first metatarsocuneiform joint.  The joint was visualized well within the surgical field.  A small joint distracter was then placed on each side of the joint and light distracter was placed and then the joint was denuded of all cartilage.  The subchondral bone was then also prepared with a burr.  The wound was irrigated with copious amount of sterile saline and the bone graft was placed.  K-wire was then utilized for temporary fixation.  This was held in place.  An AO technique was then utilized to fixate two fully threaded 3.5 cortical screws.  Excellent compression was achieved across the joint.  Excellent anatomical alignment was achieved as well as hardware fixation and confirmed on the C-arm on all view.  The wound was irrigated and closed in the exact same manner.  Next, an incision was made over the dorsomedial aspect of the first metatarsal head.  This was carried down to the capsule.  The capsule was also incised and the capsule was freed off of the medial and dorsal first metatarsal head.  There was noted to be a significant bone on the dorsal medial head, which was resected with a power sagittal saw.  All sharp bony prominences were smoothed.  The wounds were irrigated and closed in the same manner.  Sterile dressings were then applied.  Tourniquet was deflated.  The patient was transferred from the operating room to the PACU with vital signs stable and vascular status intact.  No complications encountered during the case.  The patient tolerated both the anesthesia and procedure well.


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