Relieve the Pain of Coding This Bunion Removal Case
Question: A patient presented to the orthopedic practice with pain and deformity in the right foot. The physician captured dorsoplantar and lateral X-ray views and reviewed the images. The findings revealed a bunion of the right foot. Then, the orthopedist performed a bunionectomy with a distal metatarsal osteotomy. What codes will I assign for the encounter? Ohio Subscriber Answer: Assign 28296 (Correction, hallux valgus with bunionectomy, with sesamoidectomy when performed; with distal metatarsal osteotomy, any method) to report the bunionectomy with the distal metatarsal osteotomy. Next, you’ll use 73620 (Radiologic examination, foot; 2 views) to report the X-rays of the right foot with dorsoplantar and lateral views. Laterality modifier: You’ll want to review your individual payer’s policies to confirm if they prefer you to append a modifier specifying on which side of the body the procedures were performed. In your case, you’d use modifier RT (Right side). Lastly, assign M21.611 (Bunion of right foot) to report the definitive diagnosis of the right foot bunion. Mike Shaughnessy, BA, CPC, Production Editor, AAPC
