Orthopedic Coding Alert

Don't know your DuVries from your Girdlestone?  A surgeon shows you the way

Coders have long been baffled about which codes to report for the various toe surgeries that foot surgeons perform. But if you know the assorted terms that surgeons use for these procedures, you may be on your way to coding perfection.

Even today, there is still controversy as to what constitutes a hammer toe, mallet toe or claw toe. For the purpose of this article, we will adopt the following fairly well- accepted definitions:

- Hammer toe is a supple or fixed contracture of the proximal interphalangeal joint (PIPJ) of a lessor toe.

- Mallet toe is a supple or fixed contracture of the distal interphalangeal joint (DIPJ) of a lessor toe.

- Claw toe is a supple or fixed contracture of the proximal interphalangeal joint accompanied by a supple or fixed extension deformity at the proximal metatarsophalangeal joint (MTPJ) of that toe. What causes these problems: These crooked toes originate from the imbalance of a strong extrinsic musculature and weak intrinsic musculature at the metatarsophalangeal joint complex. A chronic extensor deformity at the MTPJ destabilizes the subtle balance between extensors and flexors, resulting in deformity. Hammer Toe: From Cause to Treatment The most common causes of hammering are a constricted toe box that compresses the toes, chronic flexor digitorum tightness, diabetes and seronegative disease, disease-based muscle imbalance, and mild compartment syndrome following tibial and foot fractures. How you treat it depends on whether it is a fixed or supple deformity.

Supple hammer toe: A supple hammer toe is best repaired with the use of a flexor-to-extensor transfer (often called a Girdlestone) in which the long flexor of the toe is split and transferred to the dorsum of the proximal phalanx. There is no official code that describes this exact procedure, but since it is used to correct a hammer toe, I report 28285 (Correction, hammertoe [e.g., interphalangeal fusion, partial or total phalangectomy]).

Fixed hammer toe: A fixed hammer toe cannot be manually straightened out and needs some bony resection. A DuVries arthroplasty removes a dorsal ellipse of skin and extensor mechanism over the PIPJ, and the distal condyles of the proximal phalanx are removed with a bone cutter.

The cartilage on the base of the middle phalanx is roughened up to promote arthrofibrosis, and the complex is then straightened and fixed with a K-wire. I also code this procedure with 28285.

After I perform this procedure, if the toe still remains elevated, then there is an element of claw toe and I-ll need to perform a capsulotomy of the MTPJ (release of dorsal capsule, medial and lateral capsule and possible extensor tendon lengthening). I code this with 28270 (Capsulotomy; metatarsophalangeal joint, with or [...]