Stand Up for Better Bunionectomy Coding
When you’re told as a teen by a teacher that a small physical deformity will prevent you from doing something you love, it makes you reassess the direction you were headed. For example, something as simple as a bunion prevented me from taking pointe ballet. I still studied ballet into early adulthood, but pointe was never in the cards.
Looking back, I suppose I could have had surgery to correct the deformity, but 30 years ago bunionectomy procedures, outcomes, and recovery times were not always favorable. Often, patients were worse off than before the surgery, or the deformity came back. Bunionectomies have come a long way; surgical procedures are generally less than an hour, with a recovery of only four weeks, and the correction lasts a lifetime.
Realizing this, I finally worked up the nerve to get that long overdue bunionectomy. Before I share the details of my procedure, let’s look at how bunionectomy coding has changed for 2017.
New Procedural Codes
28291 Hallux rigidus correction with cheilectomy, debridement and capsular release of the first metatarsophalangeal joint; with implant
CPT® code 28291 was added to report hallux rigidus (bunion) correction with implant; and revised code 28289 Hallux rigidus correction with cheilectomy, debridement and capsular release of the first metatarsophalangeal joint; without implant, which describes the correction of arthritis and deformity of the joint where the head of the metatarsal bone attaches to the first bone of the greater toe, now specifies the procedure was done without an implant. Prior to 2017, code 28293 reported placement of an implant for correction of hallux valgus. Because a prosthetic implant is placed for arthritis of a joint, the descriptor for 28289 is more consistent with the condition being treated (in this instance, “implant” does not mean a screw, or plate and screw, but a prosthetic implant).
28295 Correction, hallux valgus (bunionectomy), with sesamoidectomy, when performed; with proximal metatarsal osteotomy, any method
CPT® code 28295 describes bunion correction when a proximal metatarsal osteotomy is necessary and includes sesamoidectomy, when performed. An osteotomy may be performed when there is moderate metatarsus primus varus (deviation of the first metatarsal away from the other metatarsals) and the intermetatarsal angle is greater than 40 degrees. The osteotomy is performed at the base of metatarsal or, for a long continuous osteotomy, it may start in the metatarsal neck and extend through the shaft to the base of the metatarsal.
Revised Codes: No More Legacy Names
CPT® codes 28292-28299 were revised and 28290, 28293, and 28294 were deleted to remove legacy-named procedures such as Keller, McBride, Mayo, Mitchell, Chevron, and concentric- and Lapidus-type procedures. All of the new and revised bunionectomy codes now read “sesamoidectomy, when performed,” instead of “with or without.” Instead of using the legacy names, the procedures are defined as “any method,” making it more clear that the coding is based on the location on the bone, as well as whether the correction was done using an osteotomy or fusion.
28292 Correction, hallux valgus (bunionectomy), with sesamoidectomy, when performed; with resection of proximal phalanx base, when performed, any method
CPT® code 28292 describes the correction of a hallux valgus deformity, and includes sesamoid bone removal or a proximal phalanx base resection, when necessary. The sesamoid bone removal, or removal of part of the articulating end of the bone (closest to where it attaches), realigns the toe with the metatarsal at the metatarsophalangeal joint. This is generally done for mild deformities where there is very little deviation of the metatarsal. CPT® instructs us to also use the code for simple exostectomy, previously reported with 28290.
28296 Correction, hallux valgus (bunionectomy), with sesamoidectomy, when performed; with distal metatarsal osteotomy, any method
CPT® code 28296 was revised to add the word “distal,” which describes the location of the metatarsal osteotomy. Report 28296 to correct a hallux valgus deformity with a distal metatarsal osteotomy. The procedure may also include sesamoid bone removal, when necessary, to help with bone realignment. This type of correction is done for patients with mild hallux valgus of less than 40 degrees and a minimal increase in the deviation of the metatarsal.
28297 Correction, hallux valgus (bunionectomy), with sesamoidectomy, when performed; with first metatarsal and medial cuneiform joint arthrodesis, any method
CPT® code 28297 reports a bunion correction with a joint fusion between the foot bone located behind the big toe (first metatarsal) and the bone of the middle foot located behind the first metatarsal. The fusion may be done with sesamoid bone removal, when necessary. This type of correction is done for a severe intermetatarsal angle or instability of the first tarsometatarsal joint.
28298 Correction, hallux valgus (bunionectomy), with sesamoidectomy, when performed; with proximal phalanx osteotomy, any method
CPT® code 28298 reports a bunion correction that includes a proximal phalanx osteotomy where bone is removed at the base of the big toe to help straighten it. This procedure may be performed with sesamoid bone removal, when necessary, to help with bone realignment.
28299 Correction, hallux valgus (bunionectomy), with sesamoidectomy, when performed; with double osteotomy, any method
CPT® code 28299 reports a bunion correction where two osteotomy procedures are done to straighten the toe and the metatarsal. These procedures may be done along with sesamoid bone removal, when necessary, to help with realignment. The double osteotomy can be a combination of an osteotomy of the phalanx and the metatarsal (proximal or distal) or a proximal and distal metatarsal osteotomy.
Know What’s Included
Carefully review all the codes in this range before choosing your final code for bunion correction. According to the American Medical Association’s (AMA) CPT® Assistant, all hallux valgus (bunionectomy) procedures include:
- Removal of the bony prominence (bunion)
- Removal of additional osteophytes
- Tendon releases
- Placement of internal fixation
- Removal of bursal tissue
- Articular shaving at the first metatarsophalangeal joint
Now, for the fun part. For a before image of my foot, take a look at Figure A. As you can see, the intermetarsal angle (the angle of distance between the first and second metatarsal) needs correction (approximately 15 degrees) and the alignment of the sesamoids needs improvement. The little white circles toward the toes are the sesamoids. They shouldn’t be visible. The sesamoids should be under the head of the metatarsal, which is where the toe meets the foot. Figure B shows my foot after David E. High, DPM, FACFAS, of Metro Footcare Associates surgically corrected the deformity at Brighton Surgery Center in Rochester, N.Y.
Let’s review and dissect the op report for proper coding (coding and procedural notes are highlighted in yellow):
PREOPERATIVE DIAGNOSIS: Bunion deformity right foot [M21.611]
POSTOPERATIVE DIAGNOSIS: Bunion deformity right foot
PROCEDURE: Austin bunionectomy with screw fixation right foot
PROCEDURE: The patient was brought into the operating room and placed in the supine position on the operating room table. The ankle was wrapped several times with Webril and ankle tourniquet was placed. Local anesthesia consisted of a 50:50 mixture of 0.5% Marcaine and 2% lidocaine plain. The foot was prepped and draped in the normal sterile fashion. The blood was exsanguinated with an Esmarch bandage, and ankle tourniquet was inflated to 250 mmHg for hemostasis.
Attention was then directed to the dorsal medial aspect of the right first metatarsophalangeal joint where a linear incision was made. This incision was deepened in the same plane using blunt and sharp dissection. All vital structures were identified and bleeders were ligated as necessary. The incision was deepened to the level of the periosteal capsular layer, which was reflected medially and laterally, revealing the bunion deformity.
Attention was then directed to the dorsal aspect where the extensor brevis tendon was identified and released. Attention was then directed to the first interspace where the tight lateral structures were identified and released [capsulotomy]. Then the fibular sesamoid was identified and released. The McGlamry elevator was utilized to help facilitate the release.
Attention was then directed back to the medial aspect of the metatarsal head where a portion of the medial eminence was resected. Next a K-wire was driven through the metatarsal head to act as an axis guide. The dorsum and plantar cuts were made in the Austin fashion [Austin is an upside down V cut at the metatarsal head level making it a distal metatarsal osteotomy. We know it’s distal because he is working near the metatarsal head.]. The K-wire was removed and the capital fragment was transferred laterally for reduction [osteotomy] of the deformity. Two guide wires were then driven across the osteotomy and a bone clamp was placed. Each guide wire was pre-drilled, measured, and two 2.5/14 mm Arthrex compression screws were driven across the osteotomy [placement of fixation is included in the procedure]. Excellent fixation was noted at this time. The bone clamp was removed and the redundant medial bone was resected [when they cut the bone and move it over it creates another bump; this is where the bump is being removed so the bone is flat] and the entire area was rasped until smooth. The redundant medial capsule was then resected at this time as well. The area was then copiously flushed with normal saline. The capsule was reapproximated using 3-0 Vicryl [tightening up the medial side], the subcutaneous layer closed using 4-0 Vicryl and skin closed using 5-0 nylon. A postoperative injection of Decadron was injected into the operative areas. The areas were then covered with Betadine-soaked Adaptic, 4x4s, Kling, and Coban. The ankle tourniquet was released and immediate capillary refill was noted to all digits. Patient tolerated the anesthesia and procedure well, and left the operating room to the recovery room with vital signs stable and neurovascular status intact.
Procedure coding: 28296 (excision of the exostosis is included in all bunion procedures)
Diagnosis coding: M21.611 Bunion of right foot
A postoperative surgical shoe was worn for four weeks. Ice and elevation was necessary for the first two weeks, and mild painkillers were prescribed to decrease the swelling and bruising. At two weeks, shown in Figure C, the stitches came out and modalities were started to build back strength and movement. After the surgical shoe came off, I was allowed to drive again.
The 30-year wait was worth it because the results are perfect.
Hallux Valgus Usually Runs in the Family
Adult hallux valgus occurs primarily in women; and 70 percent of patients with hallux valgus have a family history of it. Juvenile and adolescent hallux valgus often occurs bilaterally. Often pain is not the primary complaint of this deformity. Patients often also have flexible flat feet.
Clear Up Anatomy Confusion
Sometimes the terms bunion and hallux valgus are used interchangeably, and wrongly so:
A bunion is simply the prominence over the first metatarsal. This can be on the side or top of the foot, or both.
Hallux valgus is the actual deviation of the big toe toward the smaller toes. This occurs at the metatarsophalangeal joint. Multiple tendons originate in the lower leg/ankle or at the heel bone and attach to the toe. As the big toe drifts toward the other toes, the pull of the tendons causes the metatarsal to drift in the other direction.
Sesamoids are in the flexor tendons on the bottom of the foot. As the metatarsal head moves away from the second metatarsal, the sesamoids are no longer located under the metatarsal head, further causing deviation of the toe and the metatarsal. As a result, the joint capsule on the medial side of the foot stretches and the lateral side tightens up. As the condition progresses, the tendons contract and cause further deviation of the toe and the metatarsal.
The majority of bunionectomy procedures are performed to correct the deviation of the metatarsal. When correcting that deformity, the valgus deformity of the toe often corrects without the need for additional surgery, such as an osteotomy of the phalanx.
Co-written by Ruby O’Brochta-Woodward, BSN, CPC, CPMA, COSC, CSFAC, CPB, is AAPC Chapter Association treasurer and Region 7 representative. She is a clinical technical editor and educator for Decision Health, has over 40 years of experience in the medical arena, serving 30 of those years in both nursing and the business of medicine. Woodward has expertise in coding, education, auditing, and compliance, as well as orthopedic regulations. She has presented at AAPC regional and national conferences, as well as at the local level. She was a member of the AAPC ICD-10-CM training team, and has been twice selected as the Member of the Year for the Minneapolis, Minn., local chapter. Woodward has held offices of president, vice president, and member development officer of her local chapter.
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