Orthopedic Coding Alert

Don't know your DuVries from your Girdlestone?  A surgeon shows you the way

Coders have long been baffled about which codes to report for the various toe surgeries that foot surgeons perform. But if you know the assorted terms that surgeons use for these procedures, you may be on your way to coding perfection.

Even today, there is still controversy as to what constitutes a hammer toe, mallet toe or claw toe. For the purpose of this article, we will adopt the following fairly well- accepted definitions:

- Hammer toe is a supple or fixed contracture of the proximal interphalangeal joint (PIPJ) of a lessor toe.

- Mallet toe is a supple or fixed contracture of the distal interphalangeal joint (DIPJ) of a lessor toe.

- Claw toe is a supple or fixed contracture of the proximal interphalangeal joint accompanied by a supple or fixed extension deformity at the proximal metatarsophalangeal joint (MTPJ) of that toe.

What causes these problems: These crooked toes originate from the imbalance of a strong extrinsic musculature and weak intrinsic musculature at the metatarsophalangeal joint complex. A chronic extensor deformity at the MTPJ destabilizes the subtle balance between extensors and flexors, resulting in deformity.

Hammer Toe: From Cause to Treatment

The most common causes of hammering are a constricted toe box that compresses the toes, chronic flexor digitorum tightness, diabetes and seronegative disease, disease-based muscle imbalance, and mild compartment syndrome following tibial and foot fractures. How you treat it depends on whether it is a fixed or supple deformity.

Supple hammer toe: A supple hammer toe is best repaired with the use of a flexor-to-extensor transfer (often called a Girdlestone) in which the long flexor of the toe is split and transferred to the dorsum of the proximal phalanx. There is no official code that describes this exact procedure, but since it is used to correct a hammer toe, I report 28285 (Correction, hammertoe [e.g., interphalangeal fusion, partial or total phalangectomy]).

Fixed hammer toe: A fixed hammer toe cannot be manually straightened out and needs some bony resection. A DuVries arthroplasty removes a dorsal ellipse of skin and extensor mechanism over the PIPJ, and the distal condyles of the proximal phalanx are removed with a bone cutter.

The cartilage on the base of the middle phalanx is roughened up to promote arthrofibrosis, and the complex is then straightened and fixed with a K-wire. I also code this procedure with 28285.

After I perform this procedure, if the toe still remains elevated, then there is an element of claw toe and I-ll need to perform a capsulotomy of the MTPJ (release of dorsal capsule, medial and lateral capsule and possible extensor tendon lengthening). I code this with 28270 (Capsulotomy; metatarsophalangeal joint, with or without tenorrhaphy, each joint [separate procedure]) and follow with modifier 59 (Distinct procedural service) to indicate that I performed the procedure at a different site (the MTPJ, not the PIPJ).

Other Toe Conditions Require Equally Precise Coding Care

Claw toe: A flexible claw toe can often be resolved with the flexor-to-extensor transfer and coded with 28285. A fixed claw toe requires a DuVries arthroplasty at the PIPJ (28285), and a capsulotomy at the MTPJ, for which I report 28270-59. Foot surgeons may use K-wires in these procedures, but you cannot separately report the K-wire insertion.

Flexible mallet toe: A flexible mallet toe can be easily managed with a flexor tenotomy done at the plantar aspect of the PIPJ, for which I report 28232 (Tenotomy, open, tendon flexor; toe, single tendon [separate procedure]).
 
Rigid mallet toe: A rigid mallet toe responds well to a DuVries arthroplasty done at the distal interphalangeal joint (DIPJ), often accompanied by a flexor digitorum longus tenotomy done through the same incision. I also code this with 28285, and do not separately code for the flexor tendon release.

Some surgeons perform a partial resection of the base of the lessor toe proximal phalanx to further improve residual deformity. I find it a cosmetically unappealing procedure and difficult to manage postoperatively, but if your surgeon performs this procedure, you can report 28126 (Resection, partial or complete, phalangeal base, each toe).

If it must be done, the toe can often be stabilized with the use of a partial proximal syndactylization to the adjacent toe, for which you can report 28280 (Syndactylization, toes [e.g., webbing or Kelikian type procedure]). The surgeon may also use a syndactylization anytime an operated toe appears too floppy, and you should report 28280 for these procedures as well.

Angular deformities: Angular deformities of lessor toes are not uncommon and often require repair because of shoe problems. If the deformity just requires realignment of supple soft tissues (curly toe, overlapping toe), you should report 28313 (Reconstruction, angular deformity of toe, soft tissue procedures only [e.g., overlapping second toe, fifth toe, curly toes]).

With a fixed elevated rigidity of the fifth toe, a resection of the proximal phalanx with a volar plastic closure (Ruiz Mora) is an excellent choice, for which you should report 28286 (Correction, cock-up fifth toe, with plastic skin closure [e.g., Ruiz-Mora type procedure]).

Walter Pedowitz, MD, is a practicing foot and ankle surgeon, and is the CPT Advisory Committee Member for the American Orthopaedic Foot and Ankle Society.