Get Primed on Bunion Surgery Challenges
Learn confusing eponyms and techniques to help make coding easier.
By Heidi Stout, CPC, COSC, CCS-P
Coding surgical procedures to correct bunion and hallux valgus deformities can be intimidating. With a wide variety of surgical techniques that are referenced using an eponym (proper name), choosing the correct codes can be challenging, even for seasoned orthopaedic coders.
The CPT® codebook arranges bunion correction codes in a family. Only the parent code is printed in its entirety.
28290 Correction, hallux valgus (bunion), with or without sesamoidectomy; simple exostectomy (eg, Silver type procedure)
28292 Keller, McBride, or Mayo type procedure
28293 resection of joint with implant
28294 with tendon transplants (e.g., Joplin type procedure)
28296 with metatarsal osteotomy (e.g., Mitchell, Chevron, or concentric type procedures)
28297 Lapidus type procedure
28298 by phalanx osteotomy
28299 by double osteotomy
To determine the complete descriptions for the family codes, you must refer back to the parent code. The language to the left of the semi-colon in 28290, “Correction, hallux valgus (bunion), with or without sesamoidectomy,” is common to all codes in the family. Information to the right of the semi-colon is specific to the individual code.
You must also be aware that the American Medical Association (AMA) has defined a set of procedures that, when performed at the metatarsophalangeal (MTP) joint, are inclusive to the bunion correction codes 28290-28299. These inclusive procedures are:
- Synovial biopsy
- Tendon release
- Excision of the medial eminence
- Excision of associated osteophytes
- Placement of internal fixation
- Scar revision
- Articular shaving
- Removal of bursal tissue
These adjunct services should not be reported separately when performed at the MTP joint of the great toe with bunion correction surgery.
Get to Know McBride, Akin, Etc.
Many surgeons describe bunion surgery techniques using an eponym, such as Austin, Akin, McBride, and Lapidus. Unfortunately, not all of these eponyms are listed in the CPT® codebook. Because these eponyms give no information on what technique the surgeon used, code selection is difficult.
To help make sense of it all, here’s a list of bunion correction techniques and their common eponyms:
28290 – Removal of the bump (bunion) on the medial side of the toe. A common eponym is Silver.
28292 – Tightening or loosening ligaments and/or tendons to correct imbalance w/resection of the base of the proximal phalanx or head of the distal metatarsal. Common eponyms are Keller, McBride, and Mayo.
28293 – Removal of the damaged joint surfaces with prosthetic replacement. This is the only bunion procedure with no associated eponym.
28294 – Tendon transplant to correct imbalance. A common eponym is Joplin.
28296 – Osteotomy of the distal metatarsal. Common eponyms include Mitchell, Chevron, Austin, Ludloff, Kalish, Youngswick, Reverdin, and Reverdin-Green.
28297 – Fusion of the first tarsometatarsal joint plus distal soft tissue bunion repair. One common eponym is Lapidus.
28298 – Osteotomy of the proximal phalanx. A common eponym is Akin.
28299 – A double osteotomy, either of the proximal phalanx and distal metatarsal or double osteotomy of the metatarsal. Common eponyms are Logroscino and Austin-Akin.
Combinations Call for Case-by-case Knowledge
Some hallux valgus procedures include a combination of techniques that cannot be captured in a single code. One of the most common is a distal soft tissue realignment (i.e., modified McBride) combined with proximal first metatarsal osteotomy. CPT® advises reporting codes 28292 and 28306-59 Osteotomy, with or without lengthening, shortening or angular correction, metatarsal; first metatarsal-Distinct procedural service) for this technique. If Medicare is the patient’s primary insurer, however, National Correct Coding Initiative (NCCI) guidelines direct you to report 28296 for the modified McBride with proximal first metatarsal osteotomy.
Another common combination performed on patients with osteoarthritis or hallux rigidus of the first MTP joint, in addition to hallux valgus/bunion, is arthrodesis of the MTP joint with a Silver bunionectomy. Report 28750 Arthrodesis, great toe; metatarsophalangeal joint and 28290 for these procedures.
Put Your Bunion Knowledge to the Test
Diagnosis: Severe right hallux valgus deformity
Modifier McBride distal soft tissue realignment, right first MTP joint
Right proximal first metatarsal opening wedge osteotomy
Description: After induction of general anesthesia, the right lower extremity was prepped and draped in a sterile fashion. An Esmarch was used to exsanguinate the limb and the tourniquet was inflated to 250 mg. A linear incision was made in the first webspace down through subcutaneous tissue. Dissection was carried down to the adductor tendon, which was then released off its insertion. Release of the lateral joint capsule was then performed. Attention was turned medially, and a longitudinal incision was made along the first MTP joint, carried down through subcutaneous tissue, and an L-shaped capsulotomy was created. The medial eminence was exposed and resected. Attention was then directed proximally and through a separate incision, the proximal first metatarsal was exposed. Using a microsagittal saw, an osteotomy cut was made in the fit metatarsal. This was opened using a distractor and the appropriate sized locking plate was applied and secured with two screws placed proximally and distally. Excellent correction of the intermetatarsal angle was achieved. The wounds were then copiously irrigated with antibiotic solution and closed with Vicryl and nylon suture.
CPT® coding: 28292, 28306-59
Without a doubt, coding bunion surgery can be a challenge. To ensure proper and appropriate reporting and reimbursement, you must walk the walk, and talk the talk.
Heidi Stout, CPC, COSC, CCS-P, is orthopaedic coding division director at The Coding Network, LLC. She has more than 25 years experience in orthopaedic practice management. Through her consulting business, Coder-On-Call, Stout educates physicians and their staff on coding and billing compliance, provides advice on managed care contract negotiations, designs billing and documentation tools, and performs documentation audits. She is consulting editor to several medical coding publications and presents teleconferences on coding and billing issues in orthopaedic surgery. She is a member of the Monmouth, N.J., local chapter.