Wiki foot fusion and bunionectomy help

Cats3

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I am at a loss on this. is there anyone that is able to help me with this? I currently have 28110, 28308, 28297, 28270, 28730, but I am not sure!!


Progressive flatfoot deformity, right foot, with midfoot arthritis, hallux valgus, clawing of the 2nd and 3rd toes, bunionette deformity.

POSTOP DIAGNOSIS:
Progressive flatfoot deformity, right foot, with midfoot arthritis, hallux valgus, clawing of the 2nd and 3rd toes, bunionette deformity.

PROCEDURE:
Right midfoot fusion, Lapidus bunionectomy, 2nd and 5th metatarsal osteotomy, excision bunionette, correction of claw toes 2 and 3.

DESCRIPTION OF PROCEDURE:
The patient was taken to the operating room after preop discussion of risks and benefits of the procedure including damage to nerves and blood vessels, infection, and incomplete relief from pain; understanding there were no guarantees as well as her ongoing complaints of pain, difficulty with shoe wear, the patient consented to the outlined procedure, recognizing the extended recovery period. After adequate general anesthesia, preoperative regional anesthesia, and preoperative prophylactic antibiotics, the patient's right lower extremity was exsanguinated with an Esmarch bandage and tourniquet inflated to 250 mmHg. The limb was then prepped with an alcohol prep, followed by ChloraPrep prepping and draped in a normal sterile fashion. An incision was made between the 1st and 2nd interspace in the midfoot. Dissection was carried down through the subcutaneous tissue. Bleeding was controlled with electrocautery. The dorsal neurovascular bundle was identified and protected. Degenerative changes of the midfoot were easily exposed. There the degenerative changes of the anterior tibial tendon. The extensor tendons were then mobilized. The base of the 1st TMT joint, intertarsal joint, base of the 2nd metatarsal, base of the 3rd metatarsal were all individually isolated. Ultimately, a 2nd dorsal incision was made to improve access to the 3rd metatarsal. Each of these joints were then scarified, multiple trephined. Peripheral osteophytes were removed and because of the flatfoot deformity, the bone graft was then wedged into the 1st and 2nd metatarsals harvested from various osteotomy sites and the debrided exostosis. The forefoot was held in a corrected position with K-wires and then formally stabilized with screw fixation. The intercuneiform joints were fused with a 3.5 screw going from the 1st to the 2nd into the 3rd cuneiform. The 1st TMT joint was secured with 2 screws, 1 from the 1st to the 1st cuneiform and an oblique one into the 2nd and into the adjoining cuneiform. Two 7 screws were used to fuse the 2nd and 3rd TMT joints. Besides the bone graft, the DBX was injected into the dorsal osteotomies. An incision was made over the 5th metatarsal, capsule was incised. A prominent lateral eminence was removed, used as bone graft, and then a chevron osteotomy was made in the 5th metatarsal, pushing the head in a tibial direction. Excess bone was then removed. Capsule was repaired with 2-0 Vicryl. Skin closed with 3-0 nylon. An incision was made in the 2nd interspace, allowing exposure of the 2nd and 3rd metatarsals. Capsular release was then performed. The long extensor was lengthened in both cases. The 2nd metatarsal was then fully exposed and an oblique osteotomy was then made to shorten the metatarsal. This was also used as bone graft. The long extensors were then repaired with 4-0 Vicryl as was the capsule. An oblique incision was made over the 1st MTP joint. The dorsal sensory nerve was identified. The capsule was opened in a V-shaped fashion. The medial eminence as well as a dorsal cheilus were then removed. All this extra bone was used as bone graft. The toe was held in a corrected position, capsule repaired with 2-0 Vicryl. After screw fixation and K-wires were removed, the tourniquet was released. Bleeding was controlled with electrocautery. Skin incisions were closed with 3-0 nylon. A bulky sterile dressing was applied. The patient was returned to postanesthesia room in satisfactory condition. Intraoperative radiographs show correction of flatfoot deformity with midfoot fusion, shortening of the 2nd metatarsal, closing of the interspace of the 5th metatarsal, improved clinical alignment with acceptable screw fixation of the midfoot.
 
I dind't spend a lot of time on this so don't take this for indisputable, but here's what I got:
You can go either way on this but the Lapidus 1st met to medial cuneiform fusion with a bunionectomy is "partially" included in the 28730.......fusion of mutiple or transverse tarsometatarsal....just not the bunionectomy part. I chose to use the 28730 for all of the tarso/met fusions across because along with the medial eminence, a dorsal cheilus was removed up at the top of the 1st met.
28289 for the cheilectomy and bunionectomy part of the procedure.
28308 for the 2nd and 28308 for the 5th met osteotomies.
28270 for the 3rd met capsulectomy (I chose 28270 over lengthening of tendon 28234 because they were both were done through the same incision and 28270 allows more) (sounds like capsulectomy was done on 2nd at same incision as the osteotomy on the 2nd met so didn't code additional 28270 for the 2nd met)
I didn't separately code the bunionette removal (28110) because it sounded like that was through the same incision as the 28308 on the 5th met. One could argue that a 28110 should be separately coded but I didn't think it was appropriate with the 28308 unless there was documentation that the incision was lengthened down to do the osteotomy. It sounded like it was right there. Capsulectomy/otomy is included on the work done on the 5th met.
Hope this helps.
 
28730 - RT - for fusion
20900 - Bone Graft
28296 - T9 - Osteotomy
28270 - RT - Capsulotomy
28285 - T6 - hammertoe correction
28285 - T7 - hammertoe correction

*** You must make sure that these codes do not bundle. I know 28285 bundles with 28270, BUT if they are on separate toes, it is acceptable. ***
 
If you are new to foot and ankle surgery. One thing that can help is to print out foot and ankle anatomical pictures (or laminate) and mark or fill in where the procedures are being done. It is also helpful to diagram and highlight the op note and check it against the header to make sure it matches. Then, once you have all the codes you think you found, you would want to run them through an NCCI (if the payer follows) checker and list them in RVU order. Further, as stated above, you would want to check to see what bundles, if they were in separate anatomic areas, and if you can report separately or on where it was done.

This is a pretty big one for flatfoot correction with other corrections.
 
28730 - RT - for fusion
20900 - Bone Graft
28296 - T9 - Osteotomy
28270 - RT - Capsulotomy
28285 - T6 - hammertoe correction
28285 - T7 - hammertoe correction

*** You must make sure that these codes do not bundle. I know 28285 bundles with 28270, BUT if they are on separate toes, it is acceptable. ***
Respectfully disagree with this advice.

28296 is for use on the 1st MT for a bunion/hallux valgus not the 5th.
28285 x2 would not be coded in this case. There was no description of any work at the PIP joints, hammertoe mentioned, interphalangeal fusion, or phalangectomy. You can use 28285 for claw toe if a fusion is done, but there was not on here. This is the claw toe work: "An incision was made in the 2nd interspace, allowing exposure of the 2nd and 3rd metatarsals. Capsular release was then performed. The long extensor was lengthened in both cases. "
 
I dind't spend a lot of time on this so don't take this for indisputable, but here's what I got:
You can go either way on this but the Lapidus 1st met to medial cuneiform fusion with a bunionectomy is "partially" included in the 28730.......fusion of mutiple or transverse tarsometatarsal....just not the bunionectomy part. I chose to use the 28730 for all of the tarso/met fusions across because along with the medial eminence, a dorsal cheilus was removed up at the top of the 1st met.
28289 for the cheilectomy and bunionectomy part of the procedure.
28308 for the 2nd and 28308 for the 5th met osteotomies.
28270 for the 3rd met capsulectomy (I chose 28270 over lengthening of tendon 28234 because they were both were done through the same incision and 28270 allows more) (sounds like capsulectomy was done on 2nd at same incision as the osteotomy on the 2nd met so didn't code additional 28270 for the 2nd met)
I didn't separately code the bunionette removal (28110) because it sounded like that was through the same incision as the 28308 on the 5th met. One could argue that a 28110 should be separately coded but I didn't think it was appropriate with the 28308 unless there was documentation that the incision was lengthened down to do the osteotomy. It sounded like it was right there. Capsulectomy/otomy is included on the work done on the 5th met.
Hope this helps.
I agree with @nsteinhauser. There are some options. The op report could have been documented a little more clearly, a lot appears like it was the same incision and the detail is lacking. If it was better documented there *may* be more opportunity for separate coding. You will want to run this through an edit checker

28730 Flatfoot correction fusion/most of Lapidus
28289 good idea to get something for the 1st MT work since most of the work of the Lapidus (28297) is included in the 28730
28308 2nd MT osteotomy
28308 5th MT osteotomy (agree no 28110)
28270 vs. 28234 agree, one incision to get to 2 & 3. 28270 higher RVU but does have separate procedure designation so you may run into trouble there (59 mod). You would have to decide which one of these to report. I would probably do 28270.
20900 can try for the small bone graft used from the exostosis and osteotomy sites. If I remember, sometimes payers don't like this code.
 
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