# please help-claw toe repair codes needed



## twosmek (Dec 1, 2011)

please help me with coding this. All I can figure out is to code 28285 x 3 for the 2nd, 3rd, and 4th for hammertoe correction with 28270 x 3 for the capsulotomy. and then code 28234 for the 5th toe extensor tendong lengthening (but not sure if that is right)

Here is the note. 

DIAGNOSIS:
Left foot 2nd, 3rd, 4th and 5th claw toes. 
PROCEDURE:
1.  Second, third and fourth toe partial proximal phalangectomy.
2.  Second, third, fourth and fifth toe extensor tendon lengthening.
3.  Second, third and fourth toe flexor digitorum longus tenotomy.
4.  Second, third and fourth toe MTP capsulotomy.
5.  Second, third, fourth and fifth toe pinning. 
INDICATIONSt is a pleasant 62-year-old diabetic male seen by my partner for bilateral forefoot deformities.  The patient has a past medical history notable for diabetes mellitus and gastric bypass. Over the past year he has had significant deformity of his forefoot and over the dorsal aspect of his second toe, he is developing erythema and has had episodes of skin breakdown.  He also has a history notable for two Achilles tendon ruptures on the left side.  He has neuropathy but continues to have intact sensation in his feet. 
PHYSICAL EXAMINATION:
GENERAL:  The patient is in no acute distress.  I did meet with the patient inthe preoperative holding area.  He has ankle dorsiflexion on the left to 30degrees, plantar flexion to 40 degrees on the right, 10 degrees of dorsiflexionto 40 degrees of plantar flexion.  He has obvious clawing of the lesser toesbilaterally.  The first toe on the left has some slight clawing of the hallux.There is no callus formation under the metatarsophalangeal joints on any of histoes.  The skin over the second PIP joint is erythematous but no full thicknessulceration.  He has a palpable dorsalis pedis pulse bilaterally, capillaryrefill of the toes is less than two seconds throughout all toes.  The clawing ofthe toes is correctable with a fair amount of force.  There is a mild slightfixed flexion contracture at the PIP joints of approximately 20 degrees. Plain radiographs of the left foot show extension deformity at the MTP jointswith flexion deformities at the PIP joints in all of the lesser toes.  He hasmild extension deformity at the first MTP joint with no significant arthriticchanges. 
IMPRESSION AND PLAN:1.  Diabetes mellitus.2.  Peripheral neuropathy.3.  Fixed clawtoe deformity of 2nd through 5th toes.4.  Mild clawing of the hallux. 
Patient and I had a long conversation in the preoperative holding area regarding the nature of his forefoot problem.  He has been wearing extra depth shoes but has had persistent skin breakdown over the dorsal aspect of the second PIP joint and is having significant claw deformity throughout his lesser toes. I do think that he would benefit from hammertoe correction in order to preventfurther skin breakdown and risk diabetic foot ulcer.  We discussed the procedure.  He does understand the risk for vascular compromise leading to necrosis of the toe.  He understands the risk of developing floppy toes.  We did discuss potential surgical intervention for the mild clawing of the first toe,but at this point, I think that a flexure hallucis longus transfer or a Jonestype procedure would be premature.  He understands the role and rationale behindmy thoughts for his forefoot correction and would like to proceed. 
PROCEDUREatient was taken to the operating room.  He underwent a local block by our anesthesiologist preoperatively.  He underwent a general anesthetic.  The left lower extremity was prepped and draped in standard sterile fashion.Perioperative antibiotics were administered.  Procedural pause was performed.The left lower extremity was exsanguinated using an Esmarch bandage as atourniquet.  Elliptical incisions over the second, third, fourth and fifth toeswere then carried out over the PIP joints and sequentially moving from medial tolateral, the head of the proximal phalanx was exposed.  The collaterals were incised.  The plantar plate was released and the head of the proximal phalanx was removed.  I then turned my attention to the middle phalanx and the cartilaginous surface over the middle phalanx was debrided using a curette. After partial phalangectomy the toes still had some extension deformity at the MTP joint when the PIP joint was corrected.  I then turned my attention to the MTP joints; two incisions, one between the second and third metatarsals and one between the fourth and fifth metatarsals were then carried out.  The extensor digitorum longus and extensor digitorum brevis tendons were identified.  The extensor digitorum brevis tendons were released.  Z lengthening of the second, third, fourth and fifth extensor digitorum longus tendons was then carried out. Following this, there was almost complete correction of the hyperextension deformity, but there was some persistent extension.  I then proceeded to perform sequential dorsal capsulotomies over the MTP joint and then returned to the PIP joints and performed selective tenotomies of the flexor digitorum longus tendons of the second, third, fourth and fifth toes.  Following these releases, the MTP joint hyperextension was completely corrected, the PIP joint was easily reduced and the PIP joints were then pinned using 0.062 K-wires through the entire toe and into the proximal portion of the metatarsals.  I was satisfied with the position of the toes.  The Esmarch was released and all of the toes were well perfused.  The skin was then closed with 3-0 nylon suture using horizontal mattress and simple sutures.  Prior to this, a half liter of irrigation was used to wash out the wounds.  Xeroform and sterile dressing were then applied and a postop shoe was placed.  Postoperative plan will be to allow the patient to partially weight bear on his heel over the next three weeks while the pins are in place.  I will see him back in three weeks for suture removal and pin removal at that time.


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## twosmek (Dec 5, 2011)

still looking for help--please


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