Podiatry Coding & Billing Alert

Tip: Don’t automatically jump to 28298 for Aiken procedures.

Getting a lot of denials for your hallux valgus corrections, and you swear you’re pinpointing the right procedure in your coding book? You could be dealing with double osteotomies — which means there’s another hidden procedure in the op report that you’re missing.

If this is the case, your first step is to become familiar with synonyms for common bunionectomy procedures so you can easily spot a second osteotomy. For example, 28296 (Correction, hallux valgus [bunion], with or without sesamoidectomy; with metatarsal osteotomy [e.g., Mitchell, Chevron, or concentric type procedures]) is also known as an Austin procedure. Doctors might also refer to it as a metatarsal osteotomy.

Another common hallux valgus correction with multiple names is 28298 (… by phalanx osteotomy). Podiatrists may also call it a great toe osteotomy, an Aiken osteotomy, a proximal phalangeal or phalangeal osteotomy, a cheater Aiken, oblique Aiken, or a distal Aiken.

Know your terms: A bunion is an enlargement of bone or tissue around the metatarsophalangeal (MTP) joint of the first metatarsal and first toe, explains Arnold Beresh, DPM, CPC, of Peninsula Foot and Ankle Specialists PLC in Hampton, Va. It is often made worse by patients wearing shoes that are too narrow around the toe box and can cause pain and deformity of the toes.

Check out this handy Web site for more detailed explanations of different bunion procedures: www.footdoc.ca/Website Bunion (Surgery).htm.

Go Back to the Basics

After you’ve trained your eye to spot an osteotomy, the next step is to look for two separate procedures. Remember, during an osteotomy, a surgeon divides the bone and/or excises a piece of it. And the easiest way to tell if the podiatrist did a double osteotomy is to look for just that: two osteotomies. Double osteotomies could involve two in the metatarsal, or one in the proximal phalanx and one in the metatarsal.

Important: Not all bunion corrections involve osteotomies, so don’t assume that two different hallux valgus corrections are both osteotomies.  For instance, the simple resection of the medial eminence (the bony protrusion) of the first metatarsal, 28290 (… simple exostectomy [e.g., Silver type procedure]), does not involve an actual osteotomy.

Some osteotomies involve various cuts such as a "V" cut, a "Z" cut or even parallel cuts, but podiatrists still consider these single osteotomies.

Cover All of Your Bases

The bottom line is, if you see a familiar procedure name such as "Aiken," don’t jump to 28298.

Your CPT^® book does indeed call this the "Aiken procedure," but many podiatrists pair the Aiken with another osteotomy.

Tip: Usually, a double osteotomy chart note will include documentation that the podiatrist operated on two separate sites.

For example, if you see in addition to the Aiken a complex, biplanar, double-step cut through the neck of the first metatarsal, these two osteotomies would make the entire procedure a double osteotomy, and the correct code is 28299 (... by double osteotomy).

And just as the single osteotomies have several names, remember that you’ll also be dealing with interchangeable names that describe a combined distal osteotomy and phalanx osteotomy. Podiatrists may call this double procedure an Austin-Aiken, a first metatarsal and distal osteotomy, a Chevron-Aiken, or a Chevron with an osteotomy of the great toe.

Final step: Once you’ve established that the procedure is a double osteotomy, remember that osteotomies bundle soft tissue work, lengthening tendons, sesamoid work and the insertion of fixation devices such as K-wires, screws, and plates.