Wiki Need help coding this surgery

[kellit21]

Diagnosis: Painful hallux metatarsophalangeal joint with synovitis.

Operation: Arthrotomy of right hallux metatarsophalangeal joint with partial synovectomy and debridement, lavage, and minimal cheilectomy.

Description (in part): Standard dorsal arthrotomy for the hallux MP joint was utilized with incision along medial margin of the extensor hallucis longus tendon. The sagittal band on the side of the tendon was opened. The extensor brevis attachment to the dorsal base of proximal phalanx was identified and protected. The joint was opened in line with this division of the sagittal band. Mild amount of increased synovial accumulation was encountered somewhat red in appearance. It was removed and sent as specimen in formalin. There was a thickened area of capsule dorsally that could have been a source of some impengiment, so that was debrided away as well.The joint was lavaged with a liter of sterile saline. The edges of the synovial reflection were gently treated with cauterization to minimize intr-articular bleeding.

Any help is greatly appreciated!!!!

 

[krrea]

I would use 28072 and or 28052.

 

[kellit21]

Can you explain how you got these 2 codes so I can better understand?

 

[kellit21]

Can anyone help??

 

[mray906]

From what I am reading here I would use

28022 Arthrotomy metatarsophalangeal joint

28072 synovectomy metatarsophalangeal joint

 

[kellit21]

so you wouldn't code anything for the debridement, lavage, and minimal cheilectomy?

 

[mray906]

no the debridement and lavage are inclusive and the minimal cheilectomy is not mentioned in the actual body of the op report. When coding from an op report just because it is mentioned in the top portion as the procedure you would not code it unless it is in the actual body of the op report. Check with the provider to see it was actually performed.

 

[kellit21]

Thank you so much for your help!!!