Bunion and hammertoe procedures

AgnieszkaMarek

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Hello fellow codes, coding these procedures for a while and still struggling with multiply procedures performed on one toe, especially the hammertoe. here is one of the OP report.

I'm thinking of 28297 for Bunion and of course 28285 for hammertoe, anything else? Weil osteotomy always throws me off...PLEASE HELP:

PREOPERATIVE DIAGNOSIS: Painful bunion right. Hammertoe second right and dislocated second
metatarsophalangeal joint dorsally on the right.

POSTOPERATIVE DIAGNOSIS: Painful bunion right. Hammertoe second right and dislocated second
metatarsophalangeal joint dorsally on the right.

PROCEDURE:
1. Lapidus bunionectomy on the right.
2. Hammertoe correction, arthrodesis second PIPJ right.
3. Weil osteotomy second metatarsophalangeal joint right.

OPERATION AND FINDINGS: The patient was brought to the operating room and placed on the
operating room table in the supine position. Local anesthesia was achieved per
anesthesiologist with a pop/fos block. The area was then prepped and draped in the usual
sterile manner. A pneumatic ankle tourniquet was applied to the right ankle. The right foot
was then elevated and exsanguinated with an Esmarch bandage and the right ankle tourniquet
was inflated to 250 mmHg.

Attention was directed to the dorsal aspect of the right foot where a dorsal linear
incision was made approximately 12 cm in length, extending from the first
metatarsophalangeal joint to the first metatarsocuneiform joint. The incision was deepened
via sharp and blunt dissection taking care to retract and identify all vessels and nerves.
An inverted-L capsulotomy was performed at the first MPJ and the capsule from freed from
the medial eminence, which was delivered into the wound, noted to be degenerative changes
noted. Using a power saw the medial eminence was removed and all bony spicules were rasped
with an electric rasp.

Attention was then directed to the first interspace where adductor tenotomy and capsulotomy
was performed.

Attention was then directed to the first metatarsocuneiform joint, where a linear
capsulotomy was performed and all capsular tissue was freed from the dorsal, medial and
lateral aspect. Using an Arthrex retractor, the joint was opened and the cartilage was
removed off the base of the first metatarsal and along the distal aspect of the cuneiform.
The IM was reduced and the digit was put in the correct position, temporarily fixated with
a 62 K-wire and then permanently fixated with an Arthrex Nitinol screw 18 x 18 dorsal
lateral and a 3.5 Arthrex headless screw dorsal distal to proximal plantar. Noted to be
good apposition and good alignment. The area was flushed with sterile solution, further
inspected for debris. When none was found, a capsulorrhaphy was obtained using 3-0 Vicryl.
Subcu was obtained using 4-0 Vicryl and skin closure was achieved using 4-0 nylon simple
running interlocking suture. It was noted that after reducing the IM angle, we did not need
to do an Akin osteotomy. The digit was in the corrected position.

Attention was then directed to the second digit, where a dorsal linear incision was made
approximately 8 cm in length extending from the second PIPJ to he second MPJ. The incision
was deepened via sharp and blunt dissection, taking care to retract and identify all
vessels and nerves. The incision was deepened to the level of the capsule of the second
MPJ, where a linear transverse capsulotomy was performed after freeing up the extensor
tendon hood. Using a power saw, a Weil osteotomy was made dorsal distal to proximal plantar
and the head was shifted approximately 4 mm proximally and fixated with a 12-mm 2.5 Arthrex
headless screw. Dorsal to plantar, the osteotomy was stable. The dorsal lip was removed
with a rongeur and all bony spicules were rasped with an electric rasp.

Attention was then directed to the second PIPJ where using a Zimmer ToeTac, the cartilage
was removed using the reamers. The digit was put in the corrected position and the implant
was put in position as instructed and as procedure. The K-wire was driven, then through the
implant and into the second MPJ with the digit held in the corrected position.

The area was flushed with sterile saline solution, further inspected for debris. When none
was found, deep closure was obtained using 3-0 and 4-0 Vicryl suture and skin closure was
achieved using 4-0 nylon simple running interlocking sutures, simple interrupted sutures.
 

Orthocoderpgu

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Local Chapter Officer
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Salt Lake City, UT
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I'm not sure that you have the problem you think you do

The bunion repair is frequently performed at the MTP joint, but the Lapidimus is performed at the midfoot joint instead. 28297.

However the hammertoe and wiel were performed on the 2nd toe, not the big toe. So there is no bundling issue there, but you do need to use modifiers to show that the hammertoe is not related to the bunion.

Frequently the wiel is done for metatarsalgia. But I don't see it being done for that reason in this case. I would find out what condition it was treating. It could be part of the hammertoe, but I am not clear on that from the documentation.
 
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AgnieszkaMarek

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Glesns Falls, NY
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The bunion repair is frequently performed at the MTP joint, but the Lapidimus is performed at the midfoot joint instead. 28297.

However the hammertoe and wiel were performed on the 2nd toe, not the big toe. So there is no bundling issue there, but you do need to use modifiers to show that the hammertoe is not related to the bunion.

Frequently the wiel is done for metatarsalgia. But I don't see it being done for that reason in this case. I would find out what condition it was treating. It could be part of the hammertoe, but I am not clear on that from the documentation.
Thank you !
 
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