Podiatry Coding & Billing Alert

Key terms such as "metatarsal osteotomy" and "distal Aiken" can make all the difference.

Podiatrists usually perform double osteotomies to correct a patient's hallux valgus or bunion. Reporting them could result to a double whammy if you failed to recognize the warning signs pointing to a second procedure for your hallux valgus corrections. How do you handle it?

Probably the best initial step to take is to go back to the basics. Podiatrists and nonphysician practitioners operate within a defined set of vocabulary when performing bunionectomy. With this in mind, you should familiarize yourself with terms commonly used for this procedure -- and the op note is the best place to spot them. CPT 28296 (Correction, hallux valgus [bunion], with or without sesamoidectomy; with metatarsal osteotomy [e.g., Mitchell, Chevron, or concentric type procedures]) alone has two popular synonyms: Austin procedure and metatarsal osteotomy.

Likewise, 28298 (... by phalanx osteotomy) is known to some podiatrist as a great toe osteotomy, an Aiken osteotomy, a proximal phalangeal or phalangeal osteotomy, a cheater Aiken, oblique Aiken, or a distal Aiken.

Here are 3 more tips to make your hallux valgus correction billing far from being tragic.

Tip 1: Look for Double Osteotomy Signs

Don't forget that during an osteotomy, a surgeon divides the bone and/or excises a piece of it. If you spot two separate procedures that did just that, you're in for a double osteotomy ride. Double osteotomies could involve two in the metatarsal, or one in the proximal phalanx and one in the metatarsal, says Walter Pedowitz, MD, a practicing orthopedic surgeon in Linden, N.J.

No-no: 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. Procedures involving a "V" cut, a "Z" cut or even parallel cuts are also considered single osteotomies.

Know Your Anatomy: The podiatrist performs osteotomy proximal to the plantar

neck blood supply (i.e., the medial plantar artery and the first intermetatarsal plantar

artery). Osteotomy also involves the dorsal cutaneous nerve.

Tip 2: Give Your Op Note A Second Look

If you see -- in addition to an Aiken procedure -- a complex, biplanar, double-step cut through the neck of the first metatarsal, you'd know instantly that the whole procedure is a double osteotomy. Why? Many podiatrists pair the Aiken with another osteotomy, and they usually make it evident in the chart note. In this case, you'd report 28299 (... by double osteotomy) and link it to the diagnosis of hallux valgus (735.0).

Remember, physicians may interchange and conjoin a variety of names to 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.

Careful: Before you report double osteotomies, remember that osteotomies bundle soft tissue work, lengthening tendons, sesamoid work and the insertion of fixation devices such as K-wires, screws and plates. Payers would not reimburse if you report these services separately.

Tip 3: Length Doesn't Always Mean Multiple Codes

Study the following op note involving a Mau osteotomy, and learn where to fit each puzzle:

"An incision was created within the first webspace. Sharp dissection was used to get through skin only. Hemostasis was obtained with electrocautery. Tenotomy scissors were then used to bluntly dissect down into the first webspace. The abductor tendon was identified inserting on the lateral sesamoid. This was then elevated off of the sesamoid from distal to proximal while the assistant was retracting and placing tension on the tendon. The sesamoid was noted to be laterally subluxed from underneath the first metatarsal head. Next, a longitudinal incision was created over the medial aspects of the first MTP and extended down the shaft of the first metatarsal. Sharp dissection was used to get through skin and subcutaneous tissue. Hemostasis was obtained with electrocautery. Full thickness skin flaps were created, both dorsally and plantarly around the first metatarsal head. This exposed the first metatarsal phalangeal joint capsule. A longitudinal incision was created within the joint capsule. Synovial tissue was freed both dorsally and plantarly around the first metatarsal head. This exposed the medial eminence. A sagittal saw was then used to remove the medial eminence just medial to the sagittal sulcus. Next, the lateral release was then completed with a lateral capsulotomy of the first MTP joint. This adequately freed the toe and allowed appropriate positioning. Next, a modified Mau osteotomy was performed with a sagittal saw of the first metatarsal. Osteotome was used to free up the osteotomy. Next, the metatarsal head was then deviated laterally. The osteotomy was then held in place with a bone reducing forceps. The correction was checked with AP and lateral C-arm fluoroscopic images. This was deemed to be appropriate. It corrected the intermetarsal angle as well as the hallux valgus angle.

Next, a 1.8 mm. drill was used to create a pilot hole from dorsal to plantar within the first metatarsal across the osteotomy site. This was over-drilled with a 2.4 drill. A 2.4 mm. cortical lag screw was then inserted through the pilot hole. Excellent compression was obtained. Another 2.4 mm. cortical lag screw was placed slightly distal to the first one. The length as well as the position of the osteotomy was checked with standard intraoperative ap and lateral C-arm fluoroscopic images.

An elliptical incision was made directly over the PIP joint of the second toe. This was taken all the way down through the extensor hood. The collateral ligaments of the PIP joint were elevated, both medially and laterally. The condyle of the proximal phalanx was exposed. A saw was used to remove the condyles of the proximal phalanx of the second toe. A rongeur was used to remove the cartilage from the middle phalanx of the toe. Appropriate soft tissue tension was obtained.

Next, through the first webspace incision, the extensor tendon of the second toe was identified. This was Z-lengthened. This exposed the MTP joint capsule. The joint capsule was incised and freed circumferentially down to the plantar plate. This allowed appropriate correction of the second hammertoe. Next, a 0.054 K-wire was inserted from a retrograde/antegrade fashion through the PIP joint. The second MPT joint was reduced and the wire was advanced across the second MTP joint.

Next, the abductor tendon that was previously released was sewn into the periosteum of the first and second metatarsal to reinforce the bunion repair. Next, all the wounds were thoroughly irrigated with sterile saline solution.

Final intra-operatvie ap and lateral C-arm fluoroscopic images confirmed the position and correction of the hallux valgus deformity as well as the position and correction of the second hammertoe. The medial capsule was then closed with interrupted 2-0 Vicryl suture. The subcutaneous tissue was also closed with interrupted 2-0 Vicryl suture. The skin on all the incisions was closed in the standard layered fashion with 3-0 Vicryl as well as 4-0 nylon suture. A well-padded bunion wrap was applied to the right foot. A pin protector was placed over the K-wire. The tourniquet was deflated. There was appropriate vascularity with good capillary refill to all of the toes.

She was awakened by the anesthesiologist, placed supine onto a hospital stretcher and taken to the Recovery Room in stable condition. At the end of the case, all sponge and needle counts were correct."

You would code this procedure simply a double osteotomy 28299.

Argument: You might be tempted to scrap 28299, replacing them instead with bunion codes 28292 and 28296. If you bill it the way you indicate the claim will be rejected, warns Arnold Beresh, DPM, CPC, of Peninsula Foot and Ankle Specialists PLC in Hampton, Va. You cannot use two bunion codes for the same foot.