janda9092
New
- Messages
- 7
- Location
- Bethlehem, PA
Hi Podiatry Coders- I am stuck on this case. I'm not sure if the 2 anchors placed would support billing 28291 (cheilectomy w/ implant) or if they would be considered part of the EHB transfer, designating that 28289 should be billed instead. The surgeon is also requesting that the osteotomy of T5 be billed separately, as well as the EHB w/ capsular interposition transfer, which amounts to 28289,RT; 28310,59,RT; and 27691,RT.51 (-59 mod with 38310 due to separate procedure designation.) These may actually bundle. Op notes below. Thanks, in advance, for your help:
PREOPERATIVE DIAGNOSIS: Right hallux rigidus.
POSTOPERATIVE DIAGNOSIS:Right hallux rigidus.
PROCEDURES: 1. Right dorsal cheilectomy.
2. Right proximal phalanx osteotomy.
3. Right extensor hallucis brevis with capsular interposition transfer.
ANESTHESIA
opliteal, saphenous nerve block with general.
CLINICAL HISTORY: The patient has a history of previous cheilectomy performed by another surgeon. Patient has persistent pain. Radiographs showed diffuse subchondral cystic changes and degenerative changes in the hallux. Patient has elected to proceed with revision surgery. Discussed both revision cheilectomy versus fusion versus soft tissue interposition arthroplasty. Patient has elected to proceed with the latter. Indications were discussed as well as possible risks and complications including, but not limited to bleeding, infection, nerve injury, wound healing complication. Informed consent was obtained.
DESCRIPTION OF PROCEDURE: The patient was brought to the operating room. Popliteal, saphenous nerve block was administered in the holding area for postoperative pain control. After induction of general anesthetic, the right lower extremity was prepped and draped in usual sterile fashion. Right foot and ankle were exsanguinated with an Esmarch bandage. Tourniquet was inflated to 275 mmHg. Previous longitudinal incision was re-explored and extended proximally and distally. Sharp dissection carried down through subcutaneous tissues. Blunt dissection carried down until we exposed the extensor hallucis. We divided the sheath overlying the extensor hallucis, retracted it laterally, divided it. We carried dissection distally and then about the midsection of the phalanx, we sharply and transversally resected the periosteum and capsule dorsally elevating the full thickness soft tissue flap and moving it proximally until we exposed the metatarsal head. Significant degenerative changes in the metatarsals both along the phalanx and the metatarsal. We released the capsule medially and laterally, retracted it.
Using an oscillating saw, we performed the dorsal cheilectomy, resecting about 30% of the metatarsal head. We resected the medial eminence.
We then marked our osteotomy of our proximal phalanx using guidewire and then using an oscillating saw performed osteotomy of the proximal phalanx, making it oblique so that the plantar plate was intact. We removed this bone. We then mobilized the flap that included extensor hallucis brevis. Placed a tag suture using Vicryl. We then placed two anchors into the plantar aspect of the metatarsal head. It was knotless anchors. We used the modified Mason-Allen type suture in each. We took our Vicryl suture and passed it through Keith needle and passed it from dorsal to plantar to hold our capsule down and then using a knotless technique secured our two anchors. This interposed our soft tissue well covering the entire metatarsal head. We checked our construct under fluoroscopy and noted there to be motion of the sesamoids suggesting that the plantar plate was intact. Irrigated the wounds. Capsule was repaired medially using a 0-Vicryl suture. Sheath overlying the extensor hallucis re-approximated using 2-0 Vicryl sutures. Skin was closed with inverted 3-0 Vicryl sutures and staples. Xeroform, dry sterile dressings were applied. The patient tolerated the procedure well and was transferred to the PACU in stable condition. There were no intraoperative complications.
PREOPERATIVE DIAGNOSIS: Right hallux rigidus.
POSTOPERATIVE DIAGNOSIS:Right hallux rigidus.
PROCEDURES: 1. Right dorsal cheilectomy.
2. Right proximal phalanx osteotomy.
3. Right extensor hallucis brevis with capsular interposition transfer.
ANESTHESIA
opliteal, saphenous nerve block with general.CLINICAL HISTORY: The patient has a history of previous cheilectomy performed by another surgeon. Patient has persistent pain. Radiographs showed diffuse subchondral cystic changes and degenerative changes in the hallux. Patient has elected to proceed with revision surgery. Discussed both revision cheilectomy versus fusion versus soft tissue interposition arthroplasty. Patient has elected to proceed with the latter. Indications were discussed as well as possible risks and complications including, but not limited to bleeding, infection, nerve injury, wound healing complication. Informed consent was obtained.
DESCRIPTION OF PROCEDURE: The patient was brought to the operating room. Popliteal, saphenous nerve block was administered in the holding area for postoperative pain control. After induction of general anesthetic, the right lower extremity was prepped and draped in usual sterile fashion. Right foot and ankle were exsanguinated with an Esmarch bandage. Tourniquet was inflated to 275 mmHg. Previous longitudinal incision was re-explored and extended proximally and distally. Sharp dissection carried down through subcutaneous tissues. Blunt dissection carried down until we exposed the extensor hallucis. We divided the sheath overlying the extensor hallucis, retracted it laterally, divided it. We carried dissection distally and then about the midsection of the phalanx, we sharply and transversally resected the periosteum and capsule dorsally elevating the full thickness soft tissue flap and moving it proximally until we exposed the metatarsal head. Significant degenerative changes in the metatarsals both along the phalanx and the metatarsal. We released the capsule medially and laterally, retracted it.
Using an oscillating saw, we performed the dorsal cheilectomy, resecting about 30% of the metatarsal head. We resected the medial eminence.
We then marked our osteotomy of our proximal phalanx using guidewire and then using an oscillating saw performed osteotomy of the proximal phalanx, making it oblique so that the plantar plate was intact. We removed this bone. We then mobilized the flap that included extensor hallucis brevis. Placed a tag suture using Vicryl. We then placed two anchors into the plantar aspect of the metatarsal head. It was knotless anchors. We used the modified Mason-Allen type suture in each. We took our Vicryl suture and passed it through Keith needle and passed it from dorsal to plantar to hold our capsule down and then using a knotless technique secured our two anchors. This interposed our soft tissue well covering the entire metatarsal head. We checked our construct under fluoroscopy and noted there to be motion of the sesamoids suggesting that the plantar plate was intact. Irrigated the wounds. Capsule was repaired medially using a 0-Vicryl suture. Sheath overlying the extensor hallucis re-approximated using 2-0 Vicryl sutures. Skin was closed with inverted 3-0 Vicryl sutures and staples. Xeroform, dry sterile dressings were applied. The patient tolerated the procedure well and was transferred to the PACU in stable condition. There were no intraoperative complications.