Wiki Hasselman bunionectomy coding help

tinaleslie

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I am looking for some professional in-put on this chart. My physician and I are in a discussion how best to code this procedure, because he believes it is more than what CPT describes in the bunionectomy codes. He uses the Hasselman kissloc procedure. Here is the full report and the codes that we are discussing. I really want to keep an open mind and learn. Help me see this differently. Thanks in advance.

Esmarch tourniquet was used to exsanguinate the operative extremity and the tourniquet was inflated to 300 mm of mercury.

I began by making a longitudinal incision over the prominent medial eminence of the metatarsal head. I dissected through the skin and subcutaneous tissue with care to avoid injuring the dorsal medial cutaneous nerve. Once I identified and protected the nerve, I made a longitudinal incision through the medial metatarsophalangeal joint capsule and raised full thickness capsular flaps. I identified the enlarged medial eminence of the metatarsal head which I excised with a sagittal saw.

I then turned my attention to the 1st webspace. I made a longitudinal incision and dissected to the tendon of the adductor hallucis under which I placed a right-angled hemostat and transected the tendon. I then visually identified the fibular sesamoid, palpated it, and made a a longitudinal incision dorsal to the fibular sesamoid, freeing it from the contracted lateral join capsule. I then made a transverse incision in the metatarsophalangeal joint, and with a gentle reduction maneuver was able to reduce the sesamoids beneath the metatarsal head, and placed the great toe into roughly 45 degrees of varus relative to the metatarsal shaft axis, confirming that I had performed an adequate soft tissue release to correct the distal hallux valgus.

I then turned my attention to the 2nd metatarsal. Next, I exposed the 2nd metatarsophalangeal joint capsule, performed a longitudinal arthrotomy, and was able to reduce the 2nd metatarsophalangeal joint subluxation via open means. I noted a dorsal osteophyte which had formed secondary to the chronic 2nd metatarsophalangeal joint dislocation which I debrided with a rongeur. Next, i made an oblique cut proximal to the metatarsal head using a sagittal saw all which allowed me to appropriately shorten the 2nd metatarsal. I secured the metatarsal head in its shortened position with a 12 mm break-off screw, thereby completing the weil osteotomy. (CPT 28645, 28308, 28288)

At this time i turned my attention to exposing the painful arthritic 1st tarsometatarsal joint. I dissected the skin and subcutaneous tissues with care taken to avoid injuring the superficial neurovascular structures and tibialis anterior tendon. I identified the joint, examined the cartilage which demonstrated partial thickness cartilaginous degenerative changes. I removed the cartilage from the medial cuneiform and base of the 1st metatarsal using an osteotome. I then used the osteotome to shingle the distal aspect of the medial cuneiform and base of the metatarsal.

At this point I performed an open reduction of the 1st metatarsal dislocation, correcting the metatarsal abduction, dorsiflexion and pronation. I confirmed the appropriate reduction with appropriate placement of the sesamoids underneath the metatarsal head, and held this with a large point-to-point reduction clamp.

I made a small oblique incision in the safe zone of the lateral calcaneus and using a 7mm coring reamer, harvested a significant amount of cancellous bone graft from the calcaneal tuberosity. I placed and impacted this into the 1st tarsometatarsal arthrodesis site. I selected an appropriate sized Stryker locking plate to span the 1st tarsometatarsal arthrodesis site, confirmed size and position flouroscopically. I placed two locking screws of the 16mm length through the proximal holes into the medial cuneiform, then 2 locking screws of the appropriate length into the proximal 1st metatarsal.

I made an incision latereal to the 2nd metatarsal shaft. I dissected through skin and subcutaneous tissue with care taken to avoid injuring the extensor tendons and adjacent neurovascular bundle, and identified the 2nd metatarsal shaft. I was able to place a single kissloc guide wire by arthrosurface across the 2nd metatarsal, for 2nd inter metatarsal space, and into the 1st metatarsal. I used the co linear guide for the kissloc set to pass the more distal guide wire. I first passed vicryl suture loops along the path o the guidewires, followed byt the kssloc device itself. I looped the cleat medially through the loops at the 1st metatarsal. I then cinched down while confirming appropriate reduction rotation of the 1st metatarsal until the suture material changed color from white to clear over the 1st metatarsal cleat. I confirmed that the 2nd metatarsal anchor had no interposed tissue between the anchor in the bone. Once I was satisfied that the kissloc was sufficiently tightened tied a a knot over the 2nd metatarsal base plate.

At this point, I confirmed reduction of the first metatarsal and sesamoids flouroscopically.

At this point I copiously irrigated all wounds and turned my attention to completing the soft tissue repair of the 1st metatarsophalangeal joint. I excised redundant tissue from the plantar aspect of the metatarsophalangeal joint. I then excised a v-shaped portion of the plantar redundant tissue, then repaired this tissue defect using 2-0 vicryl suture. Upon doing this I noted improved alignment of the hallux valgus at the metatarsophalangeal joint. I then completed the medial capsular repair using 2-0 vicryl. I then re-irrigated all wounds, closed in anatomic layers 3-0 vicryl and 3-0 nylon. Sterile dressing consisting of betadine coated adaptic dressing, 4x4 gauze, sterile soft roll was applied. A 4 inch ace wrap was then applied. I then placed a spica type dressing to encourage maintained alignment of the 1st metatarsophalangeal joint using gauze and silk tape.

I believe this should be a simple bunionectomy code 28297 and that it includes all the soft tissue work, fusion and sesamoid reduction etc. the physician would like to code the base code 28292 and 28606 and 28740 because he is specifically treating the arthritic joint. I just don't feel that it is right since this bunionectomy code includes

  • Removal of the bony prominence (bunion)
  • Removal of additional osteophytes
  • Arthrotomy
  • Capsulotomy
  • Tenotomy
  • Tendon releases
  • Tenolysis
  • Placement of internal fixation
  • Removal of bursal tissue
  • Articular shaving at the first metatarsophalangeal joint

Bunion 28297 vs 28292, 28606, 28740
Hammertoe - CPT 28645, 28308, 28288

What am I missing?? I know of no resource that can help me with this.
 
Hi,

For the bunion repair, I will code CPT 28297 too. As per AMA, the procedure represented by code 28297 is performed to correct a hallux abductovalgus deformity with associated long first metatarsal, hypermobile first ray or instability in the first metatarsocuneiform joint, high medially deviated first metatarsocuneiform angle and arthritic changes in the first metatarsocuneiform joint. It includes the removal of prominent or hypertrophied bone from the medial aspect of the first metatarsal head (distal metaphysis) along with first metatarsal and medial cuneiform joint arthrodesis, and may additionally include the resection of excess bone at the dorsomedial, dorsal, and/or dorsolateral aspect of the metatarsal head, and/or base of the proximal phalanx with or without related soft-tissue correction, resection, or release. Code 28297 may also involve tendon and other soft-tissue balancing and/or the removal of one or both sesamoids.

However, I will also code the bone graft from the calcaneal tuberosity with the CPT 20900. AS there is no documentation whether the graft was minor or major, we can code it to minimum.

For the procedure on the second toe, I will code 28645 and 28288 as the CPT 28308 bundles with CPT 28645.
 
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