Wiki Osteoclasis without fracture for hammer toe.

[tinaleslie]

I am having trouble with the codes that the physician is reporting and what I think are the right codes. Any help would be appreciated.

The physician codes
28820
28665
28665-51
28665-51
28230
28230-51
28230-51
64450
64450-51 X6


Here is the body of the report

Prior to tournequet application using 1% lidacaine without epinephrine, I injected the tarsal tunnel so as to peripherally block the tibial nerve. I then removed the needle, injected superficially just laterally to the achilles tendon so as to peripherally block the sural nerve. I then removed the needle, injected supericially along the course of the superficial peroneal nerve as to anesthetize it. I then removed the needle, injeted deep along the course of the deep peroneal nerve at the anterior ankle so as to anesthetize it. I then removed the needle, injected the 1st webspace to anesthetize the 1st webspace common plantar digital nerve. I then removed the needle, injected the 2nd webspace to inject the 2nd webspace common plantar digital nerve. Prior to injecting at all 7 sites, I aspirated, observed no return of blood into the syringe so as to avoid injecting into a blood vessel. I injected a total of 20ml of % lidocaine.

An Esmarch tourniquet was used to exsanguinate the operative extremity and left in place in the supramalleolar region. It was placed atop sterile soft roll. This was removed at the end of the case.

I first turned my attention to the 3rd toe. I passively extended the toe at the level of the proximal interphalangeal joint. I made a stab incision plantarly, midline with care taken to avoid straying too far from midline so as to protect the plantar neurovascular bundles. I transected the flexor tendon. Then, I manually extended the toe, felt a palpable clunk aas the interphalangeal joints extended into reduced alignment, thereby completed the closed osteoclasis.

Next I turned my attention to the 4th toe. I passively extended the toe at the level of the proximal interphalangeal joint. I made a stab incision plantarly, midline with care taken to avoid straying too far from midline so as to protect the plantar neurovascular bundles. I transected the flexor tendon. Then, I manually extended the toe, felt a palpable clunk aas the interphalangeal joints extended into reduced alignment, thereby completed the closed osteoclasis.

Next I turned my attention to the 5th toe. I passively extended the toe at the level of the proximal interphalangeal joint. I made a stab incision plantarly, midline with care taken to avoid straying too far from midline so as to protect the plantar neurovascular bundles. I transected the flexor tendon. Then, I manually extended the toe, felt a palpable clunk aas the interphalangeal joints extended into reduced alignment, thereby completed the closed osteoclasis.

At this point I copiously irrigated the flexor tenotomy wounds, closed with nylon suture before addressing the chronically infected 2nd toe.

I then turned my attention to the 2nd toe. I made a full-thickness, fishmouth shaped incision at the level of the proximal phalanx. I dissected sharplydown to the bone. dissected in a subperiosteal plane down to the base of the proximal phalanx. I circumferentially open the joint capsule and removed the toe at the level of the metaatarsophalangeal joint. Identified and cauterized the nerve ends and digital vessels. I grasped the flexor tendons and transected them at the proximal most extent. I did the same to the extensor tendons. I copiously irrigated the wound, reapproximated the skin edges with nylon suture.

Sterily dressing consisiting of betadine coated adaptic dressing 4x4 guaze sterile soft roll was applied. Counts were correct x2. There was no apparent complications, I was present and scrubbed for the entire case.


From my understanding nerve blocks 64450 are not reportable. As well 28655 is for fracture treatment.

I would code this a s 28820-?? (query for laterality)
28285-??
28285-51-??
28285-51-??

Also, my understanding is the tenotomy would be included in 28285

 

[fwnewbie]

Hammertoe correction lists 28285, but tenotomy points to 28010, 28011,28232-28234,28240 with
28010- toe, single tendon, percutaneous
28011- toe, multiple tendons, percutaneous
28232-toe,single flexor tendon, open
The only code that matches the note looks like 28232. And with laterality, you need to identify the toes with HCPCS Level II modifiers.
For the manipulation of each toe to reduce fx and/or dislocation, 28675 is for open tx of interphalangeal dislocation, and I don't see any restrictions to reporting these together in my book. And I would think the dx codes would have to indicate the dislocations.
As for the local anesthesia, code 64450 is reported once per nerve plexus, nerve, or branch regardless of the number of injections performed along the nerve plexus, nerve, or branch. So, these are the nerves/branches I see: tibial, sural, superficial and deep peroneal, common plantar digital - first and second webspaces. I don't have a good reference book to help determine how many of those listed so it could be 4 or 6.
Hope this helps you.
PS I think that 28665 would only be used if someone other than the surgeon was providing the anesthesia. Not totally sure though.

 

[tinaleslie]

Thank you for your help)
So you are saying this does not meet the definition of hammer toe correction 28285 because?? .. (there was no partial or total phalangectomy?)
Also,
I did not add the heading of the note but there was general anesthesia. I was under the impression that you could not bill 64450 (nerve injections) when general anesthesia was involved. Is this right?

tl~

 

[fwnewbie]

Both methods can correct the deformity, but the description in the op note matches the flexor tenotomy. After reading the chapter guidelines on open vs closed, and since the joint itself was not opened for the manipulation, 28665 describes a closed tx of dislocation and makes sense to me now.
The nerve blocks puzzle me - if they were being done for post-op pain management, lidocaine won't last very long to give relief. I'm curious to learn whether the injections can even be coded with a general like you said.
I hope a podiatry or ortho wizard happens by to help!