Wiki Midfoot fusion w/ grafting


Birmingham, AL
Best answers
We had a patient come in who had a Lisfranc fracture that became a malunion and he developed post-traumatic arthritis. Any advice on what codes I could use would be great:

"Following sterile prep and drape, a dorsomedial incision was made over that of the proximal first and second metatarsal and the cuneiforms. We dissected through and avoided the extensor mechanism, the nerves and identified the capsule, which was opened. Large fibrotic bone chips were noted everywhere. We took away approximately 1.5 cm of proximal second metatarsal and the interspace between the Lisfranc joint of the first and second metatarsal. We cleaned this area to cancellous and cortical bone, which was clean and safe. At this point with fluoroscopic guidance, we were able to pass screws from the cuneiform to that of the second metatarsal in a similar fashion with cuneiform and the second and third metarsal and from the first metatarsal to the second metarsal with cortical screws, which were noted.

With these screws in place, we were then able to back them out and place DBX amd bone, which was taken from the distal tibia with an incision on the anteromedial tibia. We used an auger to collect autogenous cancellous bone from the distal tibia. We packed the bone with DBX into that of the wound space at this point and were able to fill the gap of the Lisfrance defect of the proximal second metatarsal and the proximal third as well as that of the interspace between the second and first metatarsal. With the screws in place and tightened, we secured this and was confirmed it with x-ray."

I've 28735 for the arthrodesis with osteotomy, but I am stumped on what code to use for the grafting. Alternatively, would 28730 with 28322 be appropriate?

I would use 28735 (fusion multiple tarsometatar. joints) with 20900-59 (bone graft separate incision). It was a fusion with osteotomy, not repair of non-union.

Fusion = the Dr. utilizes any of a variety of friction devices to hold each joint in its fused position.

Repair is not fused together but a small portion of the bone must be removed to produce a nonuion or division between the bones surfaces and aligned and stabilized with a pin.

(ref. Ingenix Coding Companion.)