Podiatry; Please Help

Sara82

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Coded 28114, 28750 and 28285(repair hammertoe).

28114 and 28750 paid. 28285(repiar of hammertoe - second through fifth) denied included in 28114(Ostectomy).

I dont usually code for podiatry and was wondering if anyone had any information to if 28285 was truly included in 28114. Per NCCI edits these are able to be seperatly billed. Any information would be greatly appriciates.

TIA
 

Sara82

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Sure thanks so much for your help; Op report copied below...

OPERATION PERFORMED:
1. Left foot first metatarsal phalangeal joint arthrodesis.
2. Metatarsal head resections of second, third, fourth and fifth digits.
3. Fixed hammertoe correction of the second fixed hammertoe deformity.
4. Correction of third fixed hammertoe deformity.
5. Correction of fourth fixed hammertoe deformity.
6. Correction of fifth fixed hammertoe deformity.

DESCRIPTION OF OPERATION:
We began by making a dorsal incision approximately 5 cm in length
over the dorsum of the left foot centered over the first metatarsophalangeal
joint. It was on the dorsum made just medial to the extensor hallucis longus.
The incision was deepened by blunt and sharp dissection with care protecting
surrounding neurovascular structures. Identified the extensor hallucis longus.
It was retracted laterally. We then made an arthrotomy with a large egress of
normal-appearing joint fluid. There is evidence of widespread advanced
arthritic changes of the great toe MTP joint. We prepared for arthrodesis by
removing residual cartilage, subchondral bone back to good bleeding bone on
both sides of the joint using combination of curettes, osteotomes, rongeurs and
perforating drills past the subchondral bone. Once we had prepared the bone
for arthrodesis, we positioned the desired position and we used several K-wires
to hold it in place. Once we had done so, we then simulated weightbearing with
a flat plate, and once we were satisfied with the position, we checked our
position again on multiple planes of fluoroscopy. Once we had positioned the
great toe in the desired position for fusion, we contoured the Accumed first
metatarsophalangeal joint arthrodesis plate over the dorsum of the first MTP
joint. We used rongeur and bur as needed, and we then placed locking screws on
both sides of the arthrodesis site, maintaining the position as described
above. Once we placed the screws in position, the arthrodesis site was quite
stable with good compression across the arthrodesis site. We once again
checked with a flat plate to verify that we had not changed our alignment
during the positioning and placement of plates and screws. Once we had
finished this, we then proceeded with metatarsal head resection. We made two
inner webspace incisions, one in the second webspace, one in the fourth
webspace of the left foot. These were longitudinal webspace incisions
approximately 4 cm in length. Using these incisions, we were able to gain
access medial and laterally to the dislocated metatarsophalangeal joints. We
were able to perform arthrotomy and elevation of the soft tissue medial and
laterally so that we could gain access to the metatarsal heads and neck
regions. Under fluoroscopic guidance, we made positioning for our metatarsal
head resections, and then we performed metatarsal head resections creating a
cascade of metatarsal head resection for the patient. This was an oblique cut,
and when we finished the cut, we elevated the soft tissues away from the head
and neck region to dissect free the resected head. On inspection, these were
all fairly profoundly affected by rheumatoid arthritis. Also chronic
dislocation had been present causing some secondary deformation of the proximal
phalanges of these toes. Once we had completed this, we used a rasp to smooth
the surface of the cut metatarsal head and neck region. At this point, we did
this for the second, third, fourth and fifth metatarsal heads. Once we had
completed this and finish rasping and smoothing the surface, we then turned to
treating the fixed hammertoe deformities. We made transverse incisions in the
second, third and fourth digits and we carried directly down to bone. We then
identified the distal aspect of the proximal phalanx of these digits where
there was fixed hammertoe deformity present. We used a sagittal saw and while
protecting the soft tissues removed enough bone so that we could gain
correction of these fixed hammertoe deformities. Prior to preparation for
arthrodesis, we removed residual cartilage and subchondral bone on the middle
phalanx joint surface side. Once we had completed this, we had good bleeding
edges for our arthrodesis and the correction of the fixed hammertoe deformities
of the second, third, and fourth digits. For the fifth digit we did the same
thing except we extended the inner webspace incision and curved it laterally so
that we could use this singular extended incision to gain access to the
proximal interphalangeal joint for fixed hammertoe correction. Once we had
prepared and performed resection and preparation for arthrodesis, all of the
toes could be brought in neutral corrected position. At this point we
irrigated with copious bacitracin laden irrigation. We then used 0.045 double-
sided K-wires to stabilize the fixed hammertoe deformity correction sites as
well as to stabilize the region of the metatarsal head resections. We first
placed the 0.045 K-wire from the fixed hammertoe correction site and extended
out to the end of the toe, and then under direct visualization we watched as we
reversed the K-wire, passed it across the fixed hammertoe correction site while
holding it in the corrected desired position. We then watched under direct
visualization as we advanced the K-wire across the metatarsophalangeal joint
and into the shaft of the metatarsals that were remaining. Once we did so, we
checked our position on multiple planes of fluoroscopy.
 
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