heatherposchman1
Networker
dx:
1. Osteoarthritis, right foot
2. Hallux limitus, right foot
3. Exostosis, right hallux
4. Hallux valgus, right foot
5. Ulcer with fat layer exposed, right hallux
6. Hammer toe, 2nd digit right foot
7. Tendon contracture, right foot
Procedure:
1. Cheilectomy 1st metatarsal, right foot
2. Akin osteotomy, right hallux
3. Exostectomy, distal right hallux
4. Debridement to subcutaneous tissue, right hallux
5. Arthroplasty, right 2nd digit
I am including only the portion of the note that describes the procedure that is in question:
This procedure was coded 28299 (for the physician's services) and the insurance is saying a more appropriate code is needed, without giving any rationale. Side note, the facility coded this same procedure 28298, 28299. There was an addition procedure performed on the 2nd digit of the same foot but that code has not been called into question.
A linear incision was carried from the dorsomedial aspect of the distal shaft of the first metatarsal to
the distal aspect of the proximal phalanx of the hallux. Retraction was provided to neurovascular structures
followed by an incision through subcutaneous tissue, deep fascia, capsule and onto bone. All bleeders were
identified and coagulated with the bo vie. The periosteum was then reflected from bone. A medial L incision
was made through the capsule into the first metatarsophalangeal joint. The hallux was then distracted allowing
the joint to be visualized. The articulating surface of the first metatarsal head was noted to be denuded of
cartilage at the central aspect with hypertrophic bone dorsally and medially. Using a sagittal saw the medial
eminence was resected from the first metatarsal head along with the hypertrophic bone dorsally. Using a burr,
the bone was contoured along the dorsal and medial aspect of the first metatarsal head until smooth.
A wedge osteotomy was performed from medial to lateral at base of the right hallux leaving the cortex
intact to reduce the hallux valgus angle. A 09x10 mm Speed Implant was applied across the osteotomy with
closure of the wedge noted. Minimal gapping was noted to the wedge which was then filled with 0.3 cc of DBX
Putty. Alignment was tested with a more rectus aligned hallux noted.
Next, a stab incision was made to medial base of the distal phalanx of the right hallux. The boney
exostosis was identified and rasped to a smooth contour. The callus to the plantar medial distal right hallux
was debrided with an underlying ulcer noted measuring 0.6 x 0.5 cm with fibrotic and granular wound base. The
fibrotic tissue was debrided with an improved granular base noted.
Sites were irrigated with saline. A piece of the 2x3 cm Epicord was implanted into the first
metatarsophalangeal joint to reduce adhesions and provide growth factors to the first metatarsal head.
Redundant joint capsule was excised. Using 3-0 vicryl the capsule and subcutaneous tissue was closed followed
by epidermal-dermal junction closure with 3-0 nylon. The distal medial incision was closed with 3-0 nylon.
Suggestions?
1. Osteoarthritis, right foot
2. Hallux limitus, right foot
3. Exostosis, right hallux
4. Hallux valgus, right foot
5. Ulcer with fat layer exposed, right hallux
6. Hammer toe, 2nd digit right foot
7. Tendon contracture, right foot
Procedure:
1. Cheilectomy 1st metatarsal, right foot
2. Akin osteotomy, right hallux
3. Exostectomy, distal right hallux
4. Debridement to subcutaneous tissue, right hallux
5. Arthroplasty, right 2nd digit
I am including only the portion of the note that describes the procedure that is in question:
This procedure was coded 28299 (for the physician's services) and the insurance is saying a more appropriate code is needed, without giving any rationale. Side note, the facility coded this same procedure 28298, 28299. There was an addition procedure performed on the 2nd digit of the same foot but that code has not been called into question.
A linear incision was carried from the dorsomedial aspect of the distal shaft of the first metatarsal to
the distal aspect of the proximal phalanx of the hallux. Retraction was provided to neurovascular structures
followed by an incision through subcutaneous tissue, deep fascia, capsule and onto bone. All bleeders were
identified and coagulated with the bo vie. The periosteum was then reflected from bone. A medial L incision
was made through the capsule into the first metatarsophalangeal joint. The hallux was then distracted allowing
the joint to be visualized. The articulating surface of the first metatarsal head was noted to be denuded of
cartilage at the central aspect with hypertrophic bone dorsally and medially. Using a sagittal saw the medial
eminence was resected from the first metatarsal head along with the hypertrophic bone dorsally. Using a burr,
the bone was contoured along the dorsal and medial aspect of the first metatarsal head until smooth.
A wedge osteotomy was performed from medial to lateral at base of the right hallux leaving the cortex
intact to reduce the hallux valgus angle. A 09x10 mm Speed Implant was applied across the osteotomy with
closure of the wedge noted. Minimal gapping was noted to the wedge which was then filled with 0.3 cc of DBX
Putty. Alignment was tested with a more rectus aligned hallux noted.
Next, a stab incision was made to medial base of the distal phalanx of the right hallux. The boney
exostosis was identified and rasped to a smooth contour. The callus to the plantar medial distal right hallux
was debrided with an underlying ulcer noted measuring 0.6 x 0.5 cm with fibrotic and granular wound base. The
fibrotic tissue was debrided with an improved granular base noted.
Sites were irrigated with saline. A piece of the 2x3 cm Epicord was implanted into the first
metatarsophalangeal joint to reduce adhesions and provide growth factors to the first metatarsal head.
Redundant joint capsule was excised. Using 3-0 vicryl the capsule and subcutaneous tissue was closed followed
by epidermal-dermal junction closure with 3-0 nylon. The distal medial incision was closed with 3-0 nylon.
Suggestions?