steigerdh
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I'm trying to code this ambulatory surgery patient with surgery on her left foot for a complex forefoot deformity with hallux valgus hypermobile first ray and lesser metatarsal phhalangeal subluxation at 2 and 3 both in the transvers plane and sagittal plane with hammertoe formation.
Pre-operative Diagnosis:
1.) Severe hallux valgus with hypermobile first ray left
2.) Retracted fibular sesamoid with first MTP subluxation and arthrosis, left
3.) Subluxed second toe in the transverse and sagittal plane with hammertoe formation, left
4.) Subluxed third toe in the transverse and sagittal plane with hammertoe formation, left
Post-operative Diagnosis: same as above.
Procedure/s:
1.) Modified McBride bunionectomy, left
2.) First metatarsal cuneiform arthrodesis, left
3.) 2nd metatarsal osteotomy, shortening and transpositional, left
4.) Hammertoe repair with proximal interphalangeal joint arthrodesis, second toe left
5.) Flexor tendon transfer, second toe left
6.) 3rd metatarsal osteotomy, shortening and transpositional, left
7.) Hammertoe repair with proximal interphalangeal joint arthrodesis, third toe left
8.) Flexor tendon transfer, 3rd toe left
Operation: The patient was transported to the OR by surgical gurney and positioned on the operating room table in the supine position. Anesthesia was provided by our anesthesiologist Dr. Jarecki. Thigh tourniquet was placed and set to 275 mm Hg. Pre-operative pause and "time-out" was performed per institutional protocol. I placed a local anesthetic block with a 1:1 mixture of 1% Lidocaine plain with 0.5% Marcaine plain 20 cc total in a modified ankle block. Typical antispetic prep and sterile draping performed.
1.) Modified McBride bunionectomy, left
Attention was directed to the dorsomedial first metatarsal where an incision was made from mid-shaft of the metatarsal to mid-shaft of the proximal phalanx. This was placed medial to the EHL and avoided the medial dorsal cutaneous nerve.
Dissection was carried through the subcutaneous layer and several veins were electrocauterized. Dorsal-medial capsulotomy was used to enter the 1st MTP joint. The medial capsular structures were underscored revealing a large medial eminenece. This was resected using a sagittal protecting the tibial sesamoidal groove. The edge was smoothed with a rasp.
Attention was then directed to the first intermetatarsal space where metzenbaum scissors were to bluntly dissect down to the lateral aspect of the 1st MTPJ. The adductor tendon was identified as was the displaced tibial sesamoid. A lateral capsulotomy was performed proximal to distal just above the sesamoid. The adductor tendon was released. Some fascial fibers from the deep transverse metatarsal ligament were also released to allow sesamoid mobilization in the frontal plane. There is abundant fibrotic tissue in the first intermetatarsal space and the fibular sesamoid was completely up in the interspace and contracted. I was not able to release it in a way that it could be relocated under the fibular sesamoidal groove so we did a fibular sesamoidectomy due to the severity of the deformity. We had talked about this at length with the patient prior to surgery.
2.) First metatarsal cuneiform arthrodesis, left
A linear incision was made from the NC joint to the distal one-third of the first metatarsal shaft. The medial dorsal cutaneous nerve branch was identified and protected. Subcutaneous dissection was carried to the level of the 1st MC joint. Transverse capsulotomy performed to enter the joint. The tibialis anterior was kept protected medially.
The cartilage surface of the medial cuneiform and the first metatarsal were then resected using an AO elevator. All debris removed with rongeur and irrigation. Once the joint was prepared I positioned the first metatarsal in a corrected position taking into account the transverse, frontal, and sagittal plane position. To achieve this I did wedge the joint slightly using a sagittal saw and refined with reciprocal planing. The joint was now well-opposed in the corrected position.
The arthrodesis site was then held reduced and compressed and provisionally fixed with a .062 k-wire driven from the metatarsal into the cuneiform.
I then looked at the joint clinically and radiographically to confirm not only the correct alignment and positioning but also good apposition at the arthrodesis site. All was as desired so I then placed permanent fixation with 2 x 3.5 mm cortical screws. The proximal screw was from the dorsal central cuneiform and existed the plantar and slightly lateral aspect of the first metatarsal. This screw was 44 mm in length. The distal screw was inserted form the dorsal central first metatarsal and aimed at the plantar medial aspect of the cuneiform. This screw was 40 mm in length. Both screws were inserted in traditional lag technique and had good purchase and provided good stability and compression at the fusion site. The site was completely opposed and in the desired position clinically and radiographically.
The intermetatarsal angle was corrected near parallel. The remaining tibial sesamoid was In good clinical alignment. I made sure not to overcorrect the intermetatarsal angle given the fibular sesamoidectomy so that we did not end up with a hallux varus. The toe was stable in the transverse plane without any tendency for varus.
Irrigation was performed and then layered closure with 3-0 vicryl on the capsule and subcutaneous layers and then 3-0 prolene on the skin.
3.) 2nd metatarsal osteotomy, shortening and transpositional, left
Incision was made over the second metatarsal with transverse section across the metatarsal phalangeal joint out onto the toe and the proximal interphalange joint. This was deepened through the subcutaneous tissues to the level of the extensor expansion. Extensor expansion release was performed. The extensor tendon was retracted laterally. The metatarsal phalangeal joint was entered with dorsal medial and lateral capsulotomy performed. This allowed exposure to the metatarsal head. Second metatarsal osteotomy with modified chevron design was performed. A more chevron medial arm in a more longitudinal lateral arm was made to provide shortening and some transposition given the abducted position of the second toe. This was provisionally fixed with a 0.062 K wire and later fixed with a 2.0 millimeter screw after we did the work on the toe. Shortening and transposition was achieved. Good stable apposition was noted.
4.) Hammertoe repair with proximal interphalangeal joint arthrodesis, second toe left
Attention was directed to the dorsal second toe and second MTP joint. Incision was made across the MTP level with a transverse portion right at the joint. This was deepened through the subcutaneous tissue and then carried out onto the second toe over the proximal interphalangeal joint which was contracted rigidly. Dissection was carried down to the proximal interphalangeal joint and the capsular structures released to expose the head of the proximal phalanx. This was done also done on the intermediate phalanx. Prep for arthrodesis was done by removing the articular cartilage on each surface. At this point in the procedure we harvested the flexor digitorum longus tendon for later transfer, see procedure below. Capsular release was performed at the MTP on the extensor expansion and the dorsal capsule. Provisional fixation was placed in the toe by using 0.062 K wire at the end of the toe and retrograded back across the arthrodesis site. The Synthes compression staple device was used to then provide for permanent fixation. The pin was kept in place and after we did the FDL tendon transfer we did place the pin across the MTP level to hold the MTP correction postoperatively. The original deformity of the toe was subluxed in the sagittal plane dorsally and laterally with abduction. I corrected this with further plantarflexed position and some adduction to compensate for this deformity to allow for best positioning postoperatively with healing.
5.) Flexor tendon transfer, second toe left
During the arthrodesis I did transfer the flexor tendon by coming through the plantar plate of the proximal interphalange joint fusion and then reflecting the brevis slips. We then transected the longus tendon and brought it up over the dorsal aspect of the phalanx and with the toe in a corrected position so the flexor tendon crossing the phalanx with 4-0 Vicryl suture. Over and over stitches x 3 were performed. The toe was held in place by the pin so there was stress shielding for the suture repair.
6.) 3rd metatarsal osteotomy, shortening and transpositional, left
Identical process for the second metatarsal he osteotomy was performed on the third metatarsal. No exceptions or deletions other than the fact that the pin fixation in the toe was not carried across the osteotomy due to angular positioning not allowing this.
7.) Hammertoe repair with proximal interphalangeal joint arthrodesis, third toe left
Identical process to the second toe was performed on the third toe with no exceptions or deletions.
8.) Flexor tendon transfer, 3rd toe left
identical process to the second toe was performed on the third toe with no exceptions or deletions.
Post-operative injection was administered with 10 cc of 0.5% Marcaine plain. Dressing consisted of betadine soaked adaptic, sterile 4x4, Kerlix, and a Jones splint.
The CPT codes I am considering using are:
CPT code 27691-LT TR/TRNSPL 1 TDN W/MUSC REDIRION/REROUTING DP
27692-LT TR/TRNSPL 1 TDN W/MUSC REDIRION/REROUTING EA TDN
28297-LT CORRJ HLX VLGS BNCTY SESMDC JOINT ARTHRODESIS
28308-XS, LT OSTEOT W/WO LNGTH SHRT/CORRJ METAR XCP 1ST EA
I'm new to coding Podiatry Procedures and would appreciate any feedback.
Pre-operative Diagnosis:
1.) Severe hallux valgus with hypermobile first ray left
2.) Retracted fibular sesamoid with first MTP subluxation and arthrosis, left
3.) Subluxed second toe in the transverse and sagittal plane with hammertoe formation, left
4.) Subluxed third toe in the transverse and sagittal plane with hammertoe formation, left
Post-operative Diagnosis: same as above.
Procedure/s:
1.) Modified McBride bunionectomy, left
2.) First metatarsal cuneiform arthrodesis, left
3.) 2nd metatarsal osteotomy, shortening and transpositional, left
4.) Hammertoe repair with proximal interphalangeal joint arthrodesis, second toe left
5.) Flexor tendon transfer, second toe left
6.) 3rd metatarsal osteotomy, shortening and transpositional, left
7.) Hammertoe repair with proximal interphalangeal joint arthrodesis, third toe left
8.) Flexor tendon transfer, 3rd toe left
Operation: The patient was transported to the OR by surgical gurney and positioned on the operating room table in the supine position. Anesthesia was provided by our anesthesiologist Dr. Jarecki. Thigh tourniquet was placed and set to 275 mm Hg. Pre-operative pause and "time-out" was performed per institutional protocol. I placed a local anesthetic block with a 1:1 mixture of 1% Lidocaine plain with 0.5% Marcaine plain 20 cc total in a modified ankle block. Typical antispetic prep and sterile draping performed.
1.) Modified McBride bunionectomy, left
Attention was directed to the dorsomedial first metatarsal where an incision was made from mid-shaft of the metatarsal to mid-shaft of the proximal phalanx. This was placed medial to the EHL and avoided the medial dorsal cutaneous nerve.
Dissection was carried through the subcutaneous layer and several veins were electrocauterized. Dorsal-medial capsulotomy was used to enter the 1st MTP joint. The medial capsular structures were underscored revealing a large medial eminenece. This was resected using a sagittal protecting the tibial sesamoidal groove. The edge was smoothed with a rasp.
Attention was then directed to the first intermetatarsal space where metzenbaum scissors were to bluntly dissect down to the lateral aspect of the 1st MTPJ. The adductor tendon was identified as was the displaced tibial sesamoid. A lateral capsulotomy was performed proximal to distal just above the sesamoid. The adductor tendon was released. Some fascial fibers from the deep transverse metatarsal ligament were also released to allow sesamoid mobilization in the frontal plane. There is abundant fibrotic tissue in the first intermetatarsal space and the fibular sesamoid was completely up in the interspace and contracted. I was not able to release it in a way that it could be relocated under the fibular sesamoidal groove so we did a fibular sesamoidectomy due to the severity of the deformity. We had talked about this at length with the patient prior to surgery.
2.) First metatarsal cuneiform arthrodesis, left
A linear incision was made from the NC joint to the distal one-third of the first metatarsal shaft. The medial dorsal cutaneous nerve branch was identified and protected. Subcutaneous dissection was carried to the level of the 1st MC joint. Transverse capsulotomy performed to enter the joint. The tibialis anterior was kept protected medially.
The cartilage surface of the medial cuneiform and the first metatarsal were then resected using an AO elevator. All debris removed with rongeur and irrigation. Once the joint was prepared I positioned the first metatarsal in a corrected position taking into account the transverse, frontal, and sagittal plane position. To achieve this I did wedge the joint slightly using a sagittal saw and refined with reciprocal planing. The joint was now well-opposed in the corrected position.
The arthrodesis site was then held reduced and compressed and provisionally fixed with a .062 k-wire driven from the metatarsal into the cuneiform.
I then looked at the joint clinically and radiographically to confirm not only the correct alignment and positioning but also good apposition at the arthrodesis site. All was as desired so I then placed permanent fixation with 2 x 3.5 mm cortical screws. The proximal screw was from the dorsal central cuneiform and existed the plantar and slightly lateral aspect of the first metatarsal. This screw was 44 mm in length. The distal screw was inserted form the dorsal central first metatarsal and aimed at the plantar medial aspect of the cuneiform. This screw was 40 mm in length. Both screws were inserted in traditional lag technique and had good purchase and provided good stability and compression at the fusion site. The site was completely opposed and in the desired position clinically and radiographically.
The intermetatarsal angle was corrected near parallel. The remaining tibial sesamoid was In good clinical alignment. I made sure not to overcorrect the intermetatarsal angle given the fibular sesamoidectomy so that we did not end up with a hallux varus. The toe was stable in the transverse plane without any tendency for varus.
Irrigation was performed and then layered closure with 3-0 vicryl on the capsule and subcutaneous layers and then 3-0 prolene on the skin.
3.) 2nd metatarsal osteotomy, shortening and transpositional, left
Incision was made over the second metatarsal with transverse section across the metatarsal phalangeal joint out onto the toe and the proximal interphalange joint. This was deepened through the subcutaneous tissues to the level of the extensor expansion. Extensor expansion release was performed. The extensor tendon was retracted laterally. The metatarsal phalangeal joint was entered with dorsal medial and lateral capsulotomy performed. This allowed exposure to the metatarsal head. Second metatarsal osteotomy with modified chevron design was performed. A more chevron medial arm in a more longitudinal lateral arm was made to provide shortening and some transposition given the abducted position of the second toe. This was provisionally fixed with a 0.062 K wire and later fixed with a 2.0 millimeter screw after we did the work on the toe. Shortening and transposition was achieved. Good stable apposition was noted.
4.) Hammertoe repair with proximal interphalangeal joint arthrodesis, second toe left
Attention was directed to the dorsal second toe and second MTP joint. Incision was made across the MTP level with a transverse portion right at the joint. This was deepened through the subcutaneous tissue and then carried out onto the second toe over the proximal interphalangeal joint which was contracted rigidly. Dissection was carried down to the proximal interphalangeal joint and the capsular structures released to expose the head of the proximal phalanx. This was done also done on the intermediate phalanx. Prep for arthrodesis was done by removing the articular cartilage on each surface. At this point in the procedure we harvested the flexor digitorum longus tendon for later transfer, see procedure below. Capsular release was performed at the MTP on the extensor expansion and the dorsal capsule. Provisional fixation was placed in the toe by using 0.062 K wire at the end of the toe and retrograded back across the arthrodesis site. The Synthes compression staple device was used to then provide for permanent fixation. The pin was kept in place and after we did the FDL tendon transfer we did place the pin across the MTP level to hold the MTP correction postoperatively. The original deformity of the toe was subluxed in the sagittal plane dorsally and laterally with abduction. I corrected this with further plantarflexed position and some adduction to compensate for this deformity to allow for best positioning postoperatively with healing.
5.) Flexor tendon transfer, second toe left
During the arthrodesis I did transfer the flexor tendon by coming through the plantar plate of the proximal interphalange joint fusion and then reflecting the brevis slips. We then transected the longus tendon and brought it up over the dorsal aspect of the phalanx and with the toe in a corrected position so the flexor tendon crossing the phalanx with 4-0 Vicryl suture. Over and over stitches x 3 were performed. The toe was held in place by the pin so there was stress shielding for the suture repair.
6.) 3rd metatarsal osteotomy, shortening and transpositional, left
Identical process for the second metatarsal he osteotomy was performed on the third metatarsal. No exceptions or deletions other than the fact that the pin fixation in the toe was not carried across the osteotomy due to angular positioning not allowing this.
7.) Hammertoe repair with proximal interphalangeal joint arthrodesis, third toe left
Identical process to the second toe was performed on the third toe with no exceptions or deletions.
8.) Flexor tendon transfer, 3rd toe left
identical process to the second toe was performed on the third toe with no exceptions or deletions.
Post-operative injection was administered with 10 cc of 0.5% Marcaine plain. Dressing consisted of betadine soaked adaptic, sterile 4x4, Kerlix, and a Jones splint.
The CPT codes I am considering using are:
CPT code 27691-LT TR/TRNSPL 1 TDN W/MUSC REDIRION/REROUTING DP
27692-LT TR/TRNSPL 1 TDN W/MUSC REDIRION/REROUTING EA TDN
28297-LT CORRJ HLX VLGS BNCTY SESMDC JOINT ARTHRODESIS
28308-XS, LT OSTEOT W/WO LNGTH SHRT/CORRJ METAR XCP 1ST EA
I'm new to coding Podiatry Procedures and would appreciate any feedback.