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Provider performed total joint replacement 1st MTPJ with a MAU bunionectomy. After reviewing op report seems a double osteotomy was performed. Provider wants to bill 28291, 28299, and 28308 even though CCI edits 28291 & 28299.
Pre-Operative Diagnosis: 1. Arthritis, left first MTPJ
2. Bunion, left foot
3. Contracture left 2nd MTPJ
Post-Operative Diagnosis: Same
Procedure: 1. 1st MTPJ Total-implant, left foot
2. Mau Bunionectomy, left foot
3. Weil Osteotomy, left 2nd metatarsal
Anesthesia: General with Pop/Saph block
Hemostasis: Pneumatic Ankle TQ 250 mmHg
EBL: Minimal
Procedure:
The patient was brought to the operating room and placed supine on the operating room table. After adequate IV sedation, a local infiltrative block was administered utilizing a 1:1 mixture of 1% Lidocaine plain and 0.5% Marcaine plain, with a total of 20cc’s used.
The left foot was then prepped and draped in the usual aseptic fashion. Upon exsanguination of the left foot with an esmark bandage and placement of padding at the ankle, the pneumatic ankle tourniquet was inflated to 250mHG.
Surgery began in the following manner:
Attention was then directed to the medial aspect of the first metatarsal head of the left foot where a curvilinear incision was made at the medial aspect of the 1st metatarsal phalangeal joint. The incision was deepened through the subcutaneous tissues using sharp and blunt dissection. Care was taken to identify and retract all vital neural and vascular structures. All bleeders were cauterized as necessary.
At this time an inverted L-shaped capsulotomy was performed at the dorsal medial aspect of the first metatarsal phalangeal joint. The periosteal and capsular structures were then carefully dissected free of the osseous attachments and reflected medially and laterally thus exposing the head of the first metatarsal and the base and shaft of the 1st proximal phalanx at the operative site.
Next an intracapsular lateral release was then performed with a 15 blade. The lateral soft tissue attachments of the fibular sesamoid were released. Utilizing a sagittal bone saw any remaining non-viable cartilage was resected and pulled from the operative field.
Next, utilizing a Reemer bone saw the metatarsal head prominences and those on the proximal phalanx of the left hallux, were resected and pulled from the operative field. Any remaining bone exostosis was removed from the proximal phalanx. Next, the base of the proximal phalanx of the hallux and head of the 1st metatarsal were resected 2 mm each. Next, utilizing standard AO principals and techniques for the Arthrosurface implant, a Large size phalangeal implant was placed in the 1st metatarsal and proximal phalanx with a 1.5mm poly betwixt them.
Next, the incision was lengthened to the midshaft of the 1st metatarsal. An osteotomy was performed from a distal dorsal to a plantar proximal orientation. The distal fragment was rotated upon the proximal, reducing the IM angle and properly aligning the 1st MTPJ, and correcting the bunion deformity. The osteotomy was fixated with a 4-hole, DJO Arsenal Plate, with 4 locking, 18 (3) and 20 (1) mm screws. C-arm was used to validate optimal positioning of both procedures.
Attention was then directed to the 2nd MTPJ. A linear incision was placed over the joint with care taken to identify and retract all vital neuro/vascular/MSK structures. A capsulotomy was performed.
The extensor tendon was identified and retracted laterally. An incision was then performed through the periosteum and capsular structures covering the head, neck and distal 1/3 of the 2nd metatarsal.
Attention was then directed to the exposed metatarsal head at which time an oscillating saw was used to produce a dorsally horizontal osteotomy. Pressure was then placed plantarly below the head of the 2nd metatarsal as the saw blade was moved in and out in a feathering motion in order for the osteotomy site to close down and shorten the 2nd metatarsal..
Next using standard AO principles and techniques (1) 2.4 mm x 14 mm cannulated screw was placed across the osteotomy site with excellent compression noted.
Pre-Operative Diagnosis: 1. Arthritis, left first MTPJ
2. Bunion, left foot
3. Contracture left 2nd MTPJ
Post-Operative Diagnosis: Same
Procedure: 1. 1st MTPJ Total-implant, left foot
2. Mau Bunionectomy, left foot
3. Weil Osteotomy, left 2nd metatarsal
Anesthesia: General with Pop/Saph block
Hemostasis: Pneumatic Ankle TQ 250 mmHg
EBL: Minimal
Procedure:
The patient was brought to the operating room and placed supine on the operating room table. After adequate IV sedation, a local infiltrative block was administered utilizing a 1:1 mixture of 1% Lidocaine plain and 0.5% Marcaine plain, with a total of 20cc’s used.
The left foot was then prepped and draped in the usual aseptic fashion. Upon exsanguination of the left foot with an esmark bandage and placement of padding at the ankle, the pneumatic ankle tourniquet was inflated to 250mHG.
Surgery began in the following manner:
Attention was then directed to the medial aspect of the first metatarsal head of the left foot where a curvilinear incision was made at the medial aspect of the 1st metatarsal phalangeal joint. The incision was deepened through the subcutaneous tissues using sharp and blunt dissection. Care was taken to identify and retract all vital neural and vascular structures. All bleeders were cauterized as necessary.
At this time an inverted L-shaped capsulotomy was performed at the dorsal medial aspect of the first metatarsal phalangeal joint. The periosteal and capsular structures were then carefully dissected free of the osseous attachments and reflected medially and laterally thus exposing the head of the first metatarsal and the base and shaft of the 1st proximal phalanx at the operative site.
Next an intracapsular lateral release was then performed with a 15 blade. The lateral soft tissue attachments of the fibular sesamoid were released. Utilizing a sagittal bone saw any remaining non-viable cartilage was resected and pulled from the operative field.
Next, utilizing a Reemer bone saw the metatarsal head prominences and those on the proximal phalanx of the left hallux, were resected and pulled from the operative field. Any remaining bone exostosis was removed from the proximal phalanx. Next, the base of the proximal phalanx of the hallux and head of the 1st metatarsal were resected 2 mm each. Next, utilizing standard AO principals and techniques for the Arthrosurface implant, a Large size phalangeal implant was placed in the 1st metatarsal and proximal phalanx with a 1.5mm poly betwixt them.
Next, the incision was lengthened to the midshaft of the 1st metatarsal. An osteotomy was performed from a distal dorsal to a plantar proximal orientation. The distal fragment was rotated upon the proximal, reducing the IM angle and properly aligning the 1st MTPJ, and correcting the bunion deformity. The osteotomy was fixated with a 4-hole, DJO Arsenal Plate, with 4 locking, 18 (3) and 20 (1) mm screws. C-arm was used to validate optimal positioning of both procedures.
Attention was then directed to the 2nd MTPJ. A linear incision was placed over the joint with care taken to identify and retract all vital neuro/vascular/MSK structures. A capsulotomy was performed.
The extensor tendon was identified and retracted laterally. An incision was then performed through the periosteum and capsular structures covering the head, neck and distal 1/3 of the 2nd metatarsal.
Attention was then directed to the exposed metatarsal head at which time an oscillating saw was used to produce a dorsally horizontal osteotomy. Pressure was then placed plantarly below the head of the 2nd metatarsal as the saw blade was moved in and out in a feathering motion in order for the osteotomy site to close down and shorten the 2nd metatarsal..
Next using standard AO principles and techniques (1) 2.4 mm x 14 mm cannulated screw was placed across the osteotomy site with excellent compression noted.