arkassabaum
Contributor
I have a large op note for coding education example purposes that is overwhelming me. Any feedback would help
Procedures
Right ankle block anesthesia.
Right Akin closing wedge osteotomy base proximal phalanx, right great toe with internal EZ clip memory staple fixation.
Right second proximal interphalangeal joint arthrodesis with internal PLLA absorbable pin fixation.
Right second toe metatarsophalangeal joint arthrotomy with debridement and scorpion repair of the volar plate and lateral collateral ligament.
Right second metatarsal Weil osteotomy with internal spinoff screw fixation.
Right second toe percutaneous extensor digitorum longus tenotomy at the proximal second metatarsal shaft level.
Right 2-3 syndactyly.
Postoperative Diagnoses
Right hallux valgus interphalangeus.
Moderately severe rigid painful right second hammertoe.
Medial and dorsal subluxation, right second metatarsophalangeal joint with crossover toe and painful intractable plantar keratosis corns, especially the dorsal medial aspect interphalangeal joint of the right great toe.
Right second metatarsalgia with long second metatarsal.
Torn volar plate right second metatarsophalangeal joint and lateral collateral ligament.
Tight extensor digitorum longus to the second toe was determined at the end of surgery after tourniquet release.
Summary
The patient was taken to the operating room and placed in the supine position, there under adequate ankle block anesthesia consisting of 1% Xylocaine mixed 50/50 with 0.5% Marcaine, a 40‑mL solution, the posterior tibial nerve, the superficial peroneal nerve, the deep peroneal nerve, the sural nerve and the saphenous nerve was injected. The patient was then draped and prepped in the usual orthopedic manner for right lower leg surgery.
The leg was elevated, Esmarch was placed, reversed on itself, and a longitudinal incision was made over the medial aspect proximal phalanx of the right great toe. The dissection was carried through the skin and subcutaneous tissue down to the capsule. The capsule of the first metatarsophalangeal joint and periosteum of the base of the proximal phalanx was released, exposing the base of the proximal phalanx and two 0.045 smooth K-wires were placed, confirming position of the osteotomy. Then, an oscillating saw was used to remove 3 mm of bone along the medial cortex in a wedge-shaped fashion. The lateral aspect of the proximal phalanx was drilled with a 0.45 smooth K-wire weakening the lateral cortex and then a greenstick closing of the osteotomy was performed. Then the wound was thoroughly irrigated with antibiotic solution and then an 8‑mm EZ clip staple was placed at the end of the procedure when the equipment was completely sterilized. X-rays were taken confirming satisfactory position and alignment with the FluoroScan.
Then, a second longitudinal incision was made over the dorsum of the PIP joint of the second toe. The dissection was carried through the skin and subcutaneous tissue down to the capsule. The capsule and extensor hood were incised longitudinally, and an oscillating saw was used to remove the cartilage and subchondral bone from the distal aspect of the proximal phalanx at right angles to the longitudinal axis of the proximal phalanx with a few degrees of angulation apex dorsal. In a similar fashion, the cartilage and subchondral bone was removed from the base of the middle phalanx at right angles to the longitudinal axis of the middle phalanx with a few degrees of angulation apex dorsal. Then, a 2.0‑mm drill was placed first antegrade then retrograde through the intramedullary canal of the proximal phalanx and distal phalanx and distal interphalangeal joint and then a 2‑mm trim and drill pin was placed first antegrade then retrograde across the DIP and PIP joints coming out of the distal aspect of the toe. Then, the pin was advanced about a quarter of an inch and cut off and then a tamp was used to countersink the pin so it would be below the surface of the bone in the tuft of the distal phalanx. Then, the toe was flexed at the PIP joint, conforming to the angulations that were previously created making more natural appearance for the toe and the wound was thoroughly irrigated with antibiotic solution again and closed with some 3-0 Dexon horizontal and vertical mattress sutures for the capsule and extensor hood, 3-0 Dexon interrupted sutures for the subcutaneous tissue and 4-0 nylon running suture for the skin.
Then, a third lazy S incision was made in the capsule and distal aspect of the second metatarsal. The capsule was exposed and there was noted to be considerable synovitis. This was debrided away and any erosions to the second metatarsophalangeal joint and a tear in the volar plate both plantar lateral and the lateral collateral ligament. Then, a curved gouge was used to free up the volar plate from the second metatarsal head and then an oscillating saw was used to cut the second metatarsal dorsal distal proximal plantar. Then, the head pusher was used to transfer the second metatarsal head proximally, approximately 2 cm and a pin was placed in the second metatarsal shaft, securing the second metatarsal head. Then, a second smooth K‑wire was placed in the mid shaft area of the proximal phalanx and a Hintermann type retractor was used to create distraction at the second metatarsophalangeal joint, aiding in the exposure of the volar plate and collateral ligament. Then, the scorpion equipment was used to place a suture in the volar plate. Two smooth drill holes were placed in the base of the proximal phalanx and the guide loop was used to bring the previously placed sutures out through the base of the proximal phalanx for later repair, then the wound was thoroughly irrigated with antibiotic solution and the lateral collateral ligament tear was identified. Some 2‑0 FiberWire, interrupted sutures were used to repair the lateral collateral ligament after it was freshened up, further stabilizing the construct. Then, the toe was placed in about 30 degrees of flexion and the volar plate was then advanced on the base of the proximal phalanx and the suture was tied, stabilizing the volar plate in its corrected position holding the toe in slight plantarflexion. The wound was thoroughly irrigated with antibiotic solution and the Hintermann retractor and pins were removed and a Weil osteotomy positioning of the second metatarsal head was performed and two 12‑mm spinoff screws were used to stabilize the second metatarsal head in its new position. Fluoroscopic x-rays were taken confirming satisfactory position and alignment of the construct and pins. Because of the severe erosion and arthritic changes to the second metatarsophalangeal joint, it was decided that a webbing procedure would be appropriate. Therefore, the incisions used for the repair of the second metatarsophalangeal joint were thoroughly irrigated and closed with some 3‑0 Dexon interrupted sutures for the capsule and extensor hood and extensor tendon, 3‑0 Dexon interrupted sutures for the subcutaneous tissue and 4‑0 nylon running suture for the skin.
Then, a fourth and fifth incision were made in the webspace between the second and third toes and the flaps were freed up dorsally and plantarly, and then the dorsal skin of the second toe was sewed to the dorsal skin of the third toe and the plantar skin of the second toe was sewed to the plantar skin of the third toe, creating a webbing between the toes using 4-0 nylon interrupted sutures.
After all of this was completed, the tourniquet was released. The foot was put into a neutral position, and the extensor digitorum longus to the second toe was noted to be tight and so with an 11‑blade scalpel, a percutaneous extensor digitorum longus tenotomy at the proximal second metatarsal shaft level was performed, eliminating this tightness to the extensor tendon. Then, the wounds were thoroughly irrigated with antibiotic solution and then the wounds were dressed with Betadine ointment, Adaptic bandages, moistened 4x4s, sterile 4x4s, ABD pads, sterile Webril, loose fitting Webril and then a right short‑leg walking Scotchcast with dorsal and volar flexion toe plate was applied and split and spread dorsally for postop swelling control. The patient tolerated all the procedures well. The tourniquet was released with 2 hours having elapsed. The patient left the operating room in good condition.
CPTS coded
28298-T5, Correction, Hallux Valgus (bunionectomy), with sesamoidectomy, when performed; with proximal phalanx osteotomy, any method (Akin on the great toe.)
28285-T6, Correction, hammertoe (eg, interphalangeal fusion, partial or total phalangectomy) (PIP fusion of the second toe; otherwise known as a hammertoe correction.)
28308-RT, Osteotomy, with or without lengthening, shortening or angular correction, metatarsal; other than first metatarsal, each (Weil osteotomy of the second metatarsal.)
28010-T6-XS, Tenotomy, percutaneous, toe; single tendon (Percutaneous tenotomy further down the second metatarsal to relieve the tightness. This code hits a NCCI edit with the hammer toe repair; however, the tendon released is in a different anatomical location than the PIP joint [being the proximal metatarsal shaft].)
28313-T6, Reconstruction, angular deformity of toe, soft tissue procedure only (eg, overlapping second toe, fifth toe, curly toes) (Repair of the volar plate and LCL. MTP arthrotomy is included per NCCI edit and will not allow a modifier.)
28280-T6, Syndactylization, toes (eg, webbing or Kelikian type procedure) (Syndactyly repair.)
Do we add 28270 for the metatarsophalangeal capsulotomy, which includes any tenorrhaphy??
Procedures
Right ankle block anesthesia.
Right Akin closing wedge osteotomy base proximal phalanx, right great toe with internal EZ clip memory staple fixation.
Right second proximal interphalangeal joint arthrodesis with internal PLLA absorbable pin fixation.
Right second toe metatarsophalangeal joint arthrotomy with debridement and scorpion repair of the volar plate and lateral collateral ligament.
Right second metatarsal Weil osteotomy with internal spinoff screw fixation.
Right second toe percutaneous extensor digitorum longus tenotomy at the proximal second metatarsal shaft level.
Right 2-3 syndactyly.
Postoperative Diagnoses
Right hallux valgus interphalangeus.
Moderately severe rigid painful right second hammertoe.
Medial and dorsal subluxation, right second metatarsophalangeal joint with crossover toe and painful intractable plantar keratosis corns, especially the dorsal medial aspect interphalangeal joint of the right great toe.
Right second metatarsalgia with long second metatarsal.
Torn volar plate right second metatarsophalangeal joint and lateral collateral ligament.
Tight extensor digitorum longus to the second toe was determined at the end of surgery after tourniquet release.
Summary
The patient was taken to the operating room and placed in the supine position, there under adequate ankle block anesthesia consisting of 1% Xylocaine mixed 50/50 with 0.5% Marcaine, a 40‑mL solution, the posterior tibial nerve, the superficial peroneal nerve, the deep peroneal nerve, the sural nerve and the saphenous nerve was injected. The patient was then draped and prepped in the usual orthopedic manner for right lower leg surgery.
The leg was elevated, Esmarch was placed, reversed on itself, and a longitudinal incision was made over the medial aspect proximal phalanx of the right great toe. The dissection was carried through the skin and subcutaneous tissue down to the capsule. The capsule of the first metatarsophalangeal joint and periosteum of the base of the proximal phalanx was released, exposing the base of the proximal phalanx and two 0.045 smooth K-wires were placed, confirming position of the osteotomy. Then, an oscillating saw was used to remove 3 mm of bone along the medial cortex in a wedge-shaped fashion. The lateral aspect of the proximal phalanx was drilled with a 0.45 smooth K-wire weakening the lateral cortex and then a greenstick closing of the osteotomy was performed. Then the wound was thoroughly irrigated with antibiotic solution and then an 8‑mm EZ clip staple was placed at the end of the procedure when the equipment was completely sterilized. X-rays were taken confirming satisfactory position and alignment with the FluoroScan.
Then, a second longitudinal incision was made over the dorsum of the PIP joint of the second toe. The dissection was carried through the skin and subcutaneous tissue down to the capsule. The capsule and extensor hood were incised longitudinally, and an oscillating saw was used to remove the cartilage and subchondral bone from the distal aspect of the proximal phalanx at right angles to the longitudinal axis of the proximal phalanx with a few degrees of angulation apex dorsal. In a similar fashion, the cartilage and subchondral bone was removed from the base of the middle phalanx at right angles to the longitudinal axis of the middle phalanx with a few degrees of angulation apex dorsal. Then, a 2.0‑mm drill was placed first antegrade then retrograde through the intramedullary canal of the proximal phalanx and distal phalanx and distal interphalangeal joint and then a 2‑mm trim and drill pin was placed first antegrade then retrograde across the DIP and PIP joints coming out of the distal aspect of the toe. Then, the pin was advanced about a quarter of an inch and cut off and then a tamp was used to countersink the pin so it would be below the surface of the bone in the tuft of the distal phalanx. Then, the toe was flexed at the PIP joint, conforming to the angulations that were previously created making more natural appearance for the toe and the wound was thoroughly irrigated with antibiotic solution again and closed with some 3-0 Dexon horizontal and vertical mattress sutures for the capsule and extensor hood, 3-0 Dexon interrupted sutures for the subcutaneous tissue and 4-0 nylon running suture for the skin.
Then, a third lazy S incision was made in the capsule and distal aspect of the second metatarsal. The capsule was exposed and there was noted to be considerable synovitis. This was debrided away and any erosions to the second metatarsophalangeal joint and a tear in the volar plate both plantar lateral and the lateral collateral ligament. Then, a curved gouge was used to free up the volar plate from the second metatarsal head and then an oscillating saw was used to cut the second metatarsal dorsal distal proximal plantar. Then, the head pusher was used to transfer the second metatarsal head proximally, approximately 2 cm and a pin was placed in the second metatarsal shaft, securing the second metatarsal head. Then, a second smooth K‑wire was placed in the mid shaft area of the proximal phalanx and a Hintermann type retractor was used to create distraction at the second metatarsophalangeal joint, aiding in the exposure of the volar plate and collateral ligament. Then, the scorpion equipment was used to place a suture in the volar plate. Two smooth drill holes were placed in the base of the proximal phalanx and the guide loop was used to bring the previously placed sutures out through the base of the proximal phalanx for later repair, then the wound was thoroughly irrigated with antibiotic solution and the lateral collateral ligament tear was identified. Some 2‑0 FiberWire, interrupted sutures were used to repair the lateral collateral ligament after it was freshened up, further stabilizing the construct. Then, the toe was placed in about 30 degrees of flexion and the volar plate was then advanced on the base of the proximal phalanx and the suture was tied, stabilizing the volar plate in its corrected position holding the toe in slight plantarflexion. The wound was thoroughly irrigated with antibiotic solution and the Hintermann retractor and pins were removed and a Weil osteotomy positioning of the second metatarsal head was performed and two 12‑mm spinoff screws were used to stabilize the second metatarsal head in its new position. Fluoroscopic x-rays were taken confirming satisfactory position and alignment of the construct and pins. Because of the severe erosion and arthritic changes to the second metatarsophalangeal joint, it was decided that a webbing procedure would be appropriate. Therefore, the incisions used for the repair of the second metatarsophalangeal joint were thoroughly irrigated and closed with some 3‑0 Dexon interrupted sutures for the capsule and extensor hood and extensor tendon, 3‑0 Dexon interrupted sutures for the subcutaneous tissue and 4‑0 nylon running suture for the skin.
Then, a fourth and fifth incision were made in the webspace between the second and third toes and the flaps were freed up dorsally and plantarly, and then the dorsal skin of the second toe was sewed to the dorsal skin of the third toe and the plantar skin of the second toe was sewed to the plantar skin of the third toe, creating a webbing between the toes using 4-0 nylon interrupted sutures.
After all of this was completed, the tourniquet was released. The foot was put into a neutral position, and the extensor digitorum longus to the second toe was noted to be tight and so with an 11‑blade scalpel, a percutaneous extensor digitorum longus tenotomy at the proximal second metatarsal shaft level was performed, eliminating this tightness to the extensor tendon. Then, the wounds were thoroughly irrigated with antibiotic solution and then the wounds were dressed with Betadine ointment, Adaptic bandages, moistened 4x4s, sterile 4x4s, ABD pads, sterile Webril, loose fitting Webril and then a right short‑leg walking Scotchcast with dorsal and volar flexion toe plate was applied and split and spread dorsally for postop swelling control. The patient tolerated all the procedures well. The tourniquet was released with 2 hours having elapsed. The patient left the operating room in good condition.
CPTS coded
28298-T5, Correction, Hallux Valgus (bunionectomy), with sesamoidectomy, when performed; with proximal phalanx osteotomy, any method (Akin on the great toe.)
28285-T6, Correction, hammertoe (eg, interphalangeal fusion, partial or total phalangectomy) (PIP fusion of the second toe; otherwise known as a hammertoe correction.)
28308-RT, Osteotomy, with or without lengthening, shortening or angular correction, metatarsal; other than first metatarsal, each (Weil osteotomy of the second metatarsal.)
28010-T6-XS, Tenotomy, percutaneous, toe; single tendon (Percutaneous tenotomy further down the second metatarsal to relieve the tightness. This code hits a NCCI edit with the hammer toe repair; however, the tendon released is in a different anatomical location than the PIP joint [being the proximal metatarsal shaft].)
28313-T6, Reconstruction, angular deformity of toe, soft tissue procedure only (eg, overlapping second toe, fifth toe, curly toes) (Repair of the volar plate and LCL. MTP arthrotomy is included per NCCI edit and will not allow a modifier.)
28280-T6, Syndactylization, toes (eg, webbing or Kelikian type procedure) (Syndactyly repair.)
Do we add 28270 for the metatarsophalangeal capsulotomy, which includes any tenorrhaphy??