Seeking opinions on how to code CPT for this case. The procedure noted on the requisition is "partial ray resection with excision sesamoids, right foot."
Because it indicates "resection," does 88309 apply? 88309 for B and 88304 for A?
SPECIMEN:
A. Tissue right metatarsal (Source: Soft tissue, debridement)
B. Right foot, hallux and sesamoids (Source: Toe, Right)
DIAGNOSIS:
A. Benign osseous tissue, right metatarsal, negative for osteomyelitis.
B. Benign skin demonstrating acute gangrenous necrosis and benign osseous tissue demonstrating acute osteomyelitis, specimen designated right hallux and sesamoid and metatarsal.
CLINICAL HISTORY:
Chronic osteomyelitis, ankle and foot right
GROSS EXAMINATION:
A. "tissue right metatarsal." The specimen consists of 2 fragments of bone, 0.6 x 0.5 x 0.2 cm and 1.2 x 0.3 x 0.2 cm. All, one following decalcification.
B. "right hallux and sesamoids and metatarsal." The specimen consists of an 8.3 x 4.0 x 3.5 cm right hallux. The medial aspect of the skin reveals a 3.0 x 1.5 cm ulcerated area with adjacent skin thickening and sloughing which is 1.5 cm from the skin and soft tissue resection margin. There is also an ulcerated area on the mid plantar surface of the skin, 0.7 x 0.5 cm which is 1.5 cm from the skin and soft tissue resection margin. The nail is intact with adjacent skin slippage. The bone underlying the lesions is softened. Also received are 4 irregular portions of bone aggregating 4.7 x 4.5 x 1.3 cm suggestive of sesamoids, and a 3.0 x 2.6 x 2.4 cm portion of bone with a primarily smooth articular surface consistent with metatarsal head. Sections: B1-perpendicular sections of inked soft tissue margin to skin lesions, B2-larger skin lesion, B3-bone of hallux following decalcification, B4-metatarsal, B5-sesamoids.
MICROSCOPIC EXAMINATION:
A. Part A demonstrates benign osseous tissue. Acellular dead bone or an inflammatory infiltrate is not identified.
B. Part B reveals benign skin demonstrating acute gangrenous necrosis. Sections of the bone reveal an acute inflammatory infiltrate representing acute osteomyelitis.
Because it indicates "resection," does 88309 apply? 88309 for B and 88304 for A?
SPECIMEN:
A. Tissue right metatarsal (Source: Soft tissue, debridement)
B. Right foot, hallux and sesamoids (Source: Toe, Right)
DIAGNOSIS:
A. Benign osseous tissue, right metatarsal, negative for osteomyelitis.
B. Benign skin demonstrating acute gangrenous necrosis and benign osseous tissue demonstrating acute osteomyelitis, specimen designated right hallux and sesamoid and metatarsal.
CLINICAL HISTORY:
Chronic osteomyelitis, ankle and foot right
GROSS EXAMINATION:
A. "tissue right metatarsal." The specimen consists of 2 fragments of bone, 0.6 x 0.5 x 0.2 cm and 1.2 x 0.3 x 0.2 cm. All, one following decalcification.
B. "right hallux and sesamoids and metatarsal." The specimen consists of an 8.3 x 4.0 x 3.5 cm right hallux. The medial aspect of the skin reveals a 3.0 x 1.5 cm ulcerated area with adjacent skin thickening and sloughing which is 1.5 cm from the skin and soft tissue resection margin. There is also an ulcerated area on the mid plantar surface of the skin, 0.7 x 0.5 cm which is 1.5 cm from the skin and soft tissue resection margin. The nail is intact with adjacent skin slippage. The bone underlying the lesions is softened. Also received are 4 irregular portions of bone aggregating 4.7 x 4.5 x 1.3 cm suggestive of sesamoids, and a 3.0 x 2.6 x 2.4 cm portion of bone with a primarily smooth articular surface consistent with metatarsal head. Sections: B1-perpendicular sections of inked soft tissue margin to skin lesions, B2-larger skin lesion, B3-bone of hallux following decalcification, B4-metatarsal, B5-sesamoids.
MICROSCOPIC EXAMINATION:
A. Part A demonstrates benign osseous tissue. Acellular dead bone or an inflammatory infiltrate is not identified.
B. Part B reveals benign skin demonstrating acute gangrenous necrosis. Sections of the bone reveal an acute inflammatory infiltrate representing acute osteomyelitis.