adunlap23
Guru
The patient presented with a second toe proximal phalanx base fracture that occurred over a month ago. So, the problem and procedures are somewhat complex.
The provider performed the following procedures:
1. Excision of fracture fragment base of second toe proximal phalanx -Would it be appropriate to code this as open fracture care even though no reduction was performed? I looked through partial excision/osteotomy codes but they seem to be directed towards bone infections and bone spurs.
2. Repair of left second toe MCP joint medial collateral ligament -I'm assuming this is unlisted, unless it is considered inclusive to the code for fx fragment excision.
Procedure:
Essentially, the fracture fragment was too small to appropriately secure with fixation. The decision was made to excise the fracture fragment. The medial collateral ligament was adhered to the fracture fragment, but the physician tried to retain as much of it as possible while excising the fracture fragment.
A stress test was performed on the MTP joint and gapping was confirmed. The decision was made to repair the collateral ligament. This was done by drilling the collateral ligament with a fiber tack suture to the site of the fracture bed.
Any advice on how to code these two procedures would be much appreciated!
The provider performed the following procedures:
1. Excision of fracture fragment base of second toe proximal phalanx -Would it be appropriate to code this as open fracture care even though no reduction was performed? I looked through partial excision/osteotomy codes but they seem to be directed towards bone infections and bone spurs.
2. Repair of left second toe MCP joint medial collateral ligament -I'm assuming this is unlisted, unless it is considered inclusive to the code for fx fragment excision.
Procedure:
Essentially, the fracture fragment was too small to appropriately secure with fixation. The decision was made to excise the fracture fragment. The medial collateral ligament was adhered to the fracture fragment, but the physician tried to retain as much of it as possible while excising the fracture fragment.
A stress test was performed on the MTP joint and gapping was confirmed. The decision was made to repair the collateral ligament. This was done by drilling the collateral ligament with a fiber tack suture to the site of the fracture bed.
Any advice on how to code these two procedures would be much appreciated!