Podiatry Coding & Billing Alert

With over 100 named hallux valgus procedures, here's what to look for in the procedure notes.

Bunionectomies are the bread and butter for many podiatry practices, but the plethora of terms and procedures that involve the big toe joint bend lots of coders out of shape. Check out our expert answers to these common bunion coding problems to help keep your coding on the straight and narrow.

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.

Question #1: There are over 100 "named" bunionectomy procedures, and only seven codes for the correction of hallux valgus. What terms should a coder look for to help determine which hallux valgus procedure code the procedure in question most closely resembles? Can we use the unlisted-procedure code?

Answer: Unfamiliar terms describing a bunionectomy should not send you scrambling for an unlisted-procedure code -- it's easy to code an unknown bunionectomy if you know the key terms associated with each bunionectomy code.

Do not use a code if it contains any terms or procedures that the podiatrist did not do, even if it otherwise perfectly describes the procedure, experts warn. The surgeon must do everything described within the CPT® code in order for a coder to be able to select it.

If none of the code descriptors accurately reflect the documented procedure, see if there are any Category III codes that fit before resorting to an unlisted-procedure code.

Use these term cues to help you quickly locate the right code:

If the podiatrist performs tendon transplants, your best bet is 28294 (Correction, hallux valgus [bunion], with or without sesamoidectomy; with tendon transplants [e.g., Joplin type procedure]).

When the surgeon removes a bony wedge from the base of the proximal phalanx, that's an osteotomy of the phalanx, also known as an Akin procedure, and you should report 28298 (... by phalanx osteotomy) or 28310 (Osteotomy, shortening, angular or rotational correction; proximal phalanx, first toe [separate procedure]).

If a metatarsal osteotomy is in the notes, you should use 28296 (Correction, hallux valgus [bunion], with or without sesamoidectomy; with metatarsal osteotomy [e.g., Mitchell, Chevron, or concentric type procedures]).

An op note that states the podiatrist performs a double osteotomy, Austin-Akin bunionectomy, closing base wedge osteotomy with Reverdin osteotomy, opening base wedge osteotomy with Reverdin osteotomy, or Austin osteotomy should lead you straight to 28299 (... by double osteotomy).

Question #2: What is a "Reverdin-Green-Laird" or "tricorrectional" bunionectomy, and how should I code this procedure?

Answer: A Reverdin-Green Laird bunionectomy procedure occurs when the podiatrist performs a metatarsal osteotomy along with the bunionectomy.

In this type of bunionectomy, the podiatrist first resects the medial eminence of the first metatarsal head, removing the bony prominent enlargement, or bunion. He then cuts though the metatarsal and repositions the metatarsal head on the metatarsal shaft, fixating the newly aligned bones with a screw fixation.

Since there is no specific code for a Reverdin-Green Laird procedure, you should use the code that most closely describes the procedure -- 28296 (Correction, hallux valgus [bunion], with or without sesamoidectomy; with metatarsal osteotomy [e.g., Mitchell, Chevron, or concentric type procedures]).

Code clue: The Austin bunionectomy is another bunionectomy procedure that falls under this code descriptor.

Question #3: Which ICD-9 codes are most commonly associated with bunionectomies?

Answer: While the obvious choice for a bunionectomy diagnosis may appear to be 727.1 (Other disorders of synovium, tendon, and bursa; bunion), this is not a code that podiatry coders should favor.

For a simple bunionectomy, or just a bump, many coders use 727.1. But if the hallux is involved or displaced, you should try to be as specific as you can and use the more descriptive codes, such 735.0 (Hallux valgus [acquired]).

Other diagnosis codes coders most commonly report using are 735.1 (Hallux varus [acquired]), 735.2 (Hallux rigidus), and 754.52 (Congenital metatarsus primus varus).

Question #4: We've been having problems with our insurers bundling hammertoe surgeries into our modified McBride procedures when the podiatrist performs these procedures on the same foot. Did a new CCI edit come out? We've tried using modifier 51 to no avail.

Answer: Yes, Correct Coding Initiative (CCI) edits do bundle hammertoe corrections into bunionectomies. If you're not using the correct location modifiers, that could be the problem.

Best way: To indicate to the carrier that the podiatrist performed the procedures on distinct toes, use the toe modifiers, such TA (Left foot, great toe) and T3 (Left foot, fourth digit), rather than LT (Left side) and 51 (Multiple procedures). You should also append modifier 59 (Distinct procedural services) to indicate that the hammertoe is a distinct procedure from the bunionectomy.

Example: A podiatrist performs a modified McBride (28292, Correction, hallux valgus [bunion], with or without sesamoidectomy; Keller, McBride, or Mayo type procedure) on toe TA and a hammertoe correction (28285, Correction, hammertoe [e.g., interphalangeal fusion, partial or total phalangectomy]) on toe T3.

You should code the modified McBride as 28292-TA as the first procedure, and the lower-RVU hammertoe correction second as 28285-T3-59. The toe modifiers show that the podiatrist performed the procedures on separate toes.

Don't do this: Do not append modifier 22 (Unusual procedural services) to the McBride because the op report says "modified." Always code a McBride of any kind as just a McBride.