Wiki 28306? 28270? Or 28296

[MELJNBBRB]

Grasping a lot of these, but I am stumped on this one, Suggestions from any Podiatry gurus out there on how YOU would code this note.

TIA<
MJNB,CCS,CPC



Preoperative Diagnosis/es:

# 1 Malalignment syndrome, 1st MPJ , RIGHT
# 2 Metatarsus primus adductus, RIGHT

Postoperative Diagnosis/es:

-SAME

OPERATIONS Performed:

# 1 Osteotomy, proximal (closing base wedge), 1st metatarsal, , RIGHT
# 2 Bunionectomy with lateral soft tissue release,, RIGHT
>> Hallux, T5 (right 1st)


Anesthesia: General Anesthesia
Fluids: 500cc Lactated Ringers
Injectables:1:1 mix of Lidocaine 2% & Marcaine 0.5% (without epinephrine), 6 cc
Hemostasis (pneumatic tourniquet) :ankle, RIGHT At 250 mmHg
Tourniquet time: Right = 55 minutes
EBL: None
Pathology: none needed
Materials used:
>> Suture:4-0 biosyn and 3-0 polysorb
>> Fixation: Osteomed H plate with 2.7 screws, 14 x2, 16, 18, Threaded kwire - buried

PREPARATION:

> patient placed on operative table in supine and secured
> time out performed:
reconfirming patient identity, consented procedures and surgical sites
all members of the surgical team identified themselves
> padded pneumatic tourniquet applied to RIGHT
> after induction of anesthesia:
preoperative injectables applied
sterile prep and drape
>RIGHT raised, manually compressed, tourniquet inflated


OPERATION SUMMARY:
Incision: dorso-medial linear longitudinal from 1st metatarsal base to distal to 1st MPJ
Dissection; blunt/sharp to periosteal level, coagulating small venous structures as needed
-bluntly over 1st MPJ into first interspace where the insertion of the conjoined tendon was released from insertion into lateral aspect of fibular sesamoid and base of proximal phalanx
-dorso-medial linear longitudinal cut/reflection of periosteum exposing proximal base of 1st metatarsal
-axis k wire driven from dorsal to plantar, in medial cortex 15 mm from base, oriented perpedicular to the dorsa cortex of 1st metatarsal
-via osteotomy guide, a 4 mm lateral based transverse wedge cut/removed
-osseous hinge feather to close osteotomy which was pinned laterally with threaded kwire
-reduction of deformity and position of bone confirmed via fluoroscopy
-locking plate/screws applied medially, spanning the osteotomy - position confirmed via fluroscopy
-threaded kwire cut above cortex
-dorso-medial linear cut/reflection of capsule off medial 1st metatarsal head
-medial 1st metatarsal head prominence removed
-inspection: no further medial prominence of 1st metatarsal head, smooth ROM of 1st MPJ
Irrigation:
30 cc saline
Closure: capsule/periosteum with polysorb, skin with biosyn
Tourniquet: released, capillary refill returned to foot/digits
Dressing: steristrips, gauze, webril, coban

Patient tolerated procedure well
Awakened by anesthesia service
Taken to recovery
Post op instructions will be dispensed/reviewed
Follow up care scheduled at Podiatry Clinic

 

[nsteinhauser]

Not a 'guru' here but 2 things I looked at. First - a description from an old bunion bulletin from AAOS:
28296 - ; with metatarsal osteotomy (e.g. Mitchell, Chevron or concentric type procedures) This procedure includes a distal metatarsal osteotomy. AAOS states that this procedure includes: arthrotomy, synovial biopsy, tendon release or transfer, synovectomy, capsular release and reconstruction, removal of additional exostoses in the area of the joint, internal fixation, articular shaving, arthroscopy, removal of bursal tissue, repair of released tendon, implant insertion, local bone graft and allows additional coding and report for: phalangeal osteotomy to correct deformity, harvesting and insertion of bone graft from distant site (separate skin or fascial incision), and ankle tendon lengthening.
Based on that, the 28296 covers the wedge osteotomy at the base and the tendon release and capsulectomy. But - second - I was wondering if it would also include the "medial first metatarsal head prominence removed." If you look in the cpt book at the picture for the 28296, the picture includes the removal of the medial eminence along with the metatarsal osteotomy in the code. This isn't the same as removal of the metatarsal head prominence, but based on this, I think cpt would bundle that into the 28296 as well.
Hope this helps.

 

[solocoder]

28290 ? ; simple exostectomy This procedure is just that?a simple exostectomy.
AAOS states that this procedure includes: arthrotomy, synovial biopsy, extensor tenotomy, synovectomy, capsular release and reconstruction, removal of additional exostoses in the area of that joint, internal fixation, articular shaving, arthroscopy, removal of bursal tissue, excision of redundant skin and closure, capsular arthroplasty, excision of bone or synovial cysts and allows additional coding and report for: phalangeal osteotomy to correct deformity, proximal first metatarsal osteotomy and ankle tendon lengthening.

So, it comes down to payer. CCI edits bundle your metatarsal osteotomy
(28306) with 28290, and all other bunion sx. But for non-medicare, I bill both codes, have to send notes to get 28306 paid, but it gets paid.

 

[nsteinhauser]

The base of the 1st metatarsal was exposed and a 'lateral based wedge cut/removed.' This alone would be an osteotomy of the 1st metatarsal - so the 28306 - but with the tendon lengthening and capsulotomy and exostectomy off the metatarsal head, wouldn't it fall under the 28296? Seems like what was done was more than what is included in a 28290 versus what is included in a 28296. Thoughts?

 

[solocoder]

I just noticed your op note doesn't say if the metarsal osteotomy was distal or proximal. That detail will make a difference in code selection. Per AAOS 28296 is for distal osteotomy.