Question: Our podiatrist documented the following:
Diagnosis: 2nd Metatarsophalangeal stiffness
The patient was taken to the operating room where she received left ankle local block anesthetic with approximately 8cc of 1% Lidocaine and 0.5% Marcaine. The 2nd MP right foot which previously had a 10 degree extension contracture was stretched into approximately 30 degrees of plantar flexion.
This procedure was done at the same time and the surgeon wants to use 28120 (Partial excision [craterization, saucerization, sequestrectomy, or diaphysectomy] bone [e.g., osteomyelitis or bossing]; talus or calcaneus):
Diagnosis: Left calcaneal ununited anterior process fracture
An approximately 3 cm incision in the anterior process of the calcaneus with bony prominence was then made. The EDB was separated around this bony fragment. The bony prominence was then removed with a combination of a rongeur and a key elevator through the fibrous union plane. After this had been removed, the surface of the bone was smoothed with a rongeur as there was a slight bony edge. This was flat after this. It was irrigated with antibiotics irrigation.
How do we report these?
Answer: You report 28899 (Unlisted procedure, foot or toes) for the stretch your surgeon does for the contracture. It is correct to report 28120 for calcaneal excision.
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