ortho1991
Guru
Hi All I hope someone can help with this.
Here is the op-note we billed 28730,TA 28308,T1 28270,T1 and 20900 and only received payment for 28730,TA.
We will add modifier 59 on the 28308 that is a separate toe, my question is should we also be paid for the 28270 or is it included in the 28308?
Any help or suggestion with this will be much appreciated. Thank you
PROCEDURES:
1. Left first tarsometatarsal arthrodesis.
2. Left second metatarsal shortening osteotomy.
3. Left second metatarsophalangeal joint capsulorrhaphy and release.
4. Calcaneal bone graft auto harvest.
5. Use of an interpretation of fluoroscopic images of the foot.
COMPLICATIONS: None.
CONDITION: Stable to recovery room.
The patient was brought to the operating room where he was placed supine on the
OR table. Left lower extremity was prepped and draped in the usual sterile
fashion. Timeout was conducted to confirm the correct patient, site and side of
surgery. Perioperative antibiotics were given in the form of Kefzol IV.
Left lower extremity was exsanguinated with an Esmarch and the Esmarch was used
as a tourniquet about the ankle, which was well padded with Webril. I utilized
a dorsal approach to the first TMT joint. Skin and soft tissues were carefully
dissected avoiding any neurovascular structures. EHL tendon was identified,
protected and retracted throughout the entirety of the case. A capsule was
incised in line with the skin incision. I encountered hypertrophic osteophyte
formation on the dorsal aspect of the first TMT joint, which was removed with a
rongeur. I was able then to examine the joint, which showed arthrosis with full
thickness cartilage loss, periarticular sclerosis and osteophyte formation.
I used a combination of osteotomes and a sagittal saw to resect the remaining
articular surface of the joint. I then penetrated the subchondral bone,
fenestrated with the 0.062 K-wire multiple times to prepare for fusion. I then
roughened up the articular surfaces with a Hoke osteotome. I then effected
reduction opposing the 2 articular surfaces together with crossing 0.062
K-wires. After I was happy with the position of the arthrodesis, I proceeded to
drill, measure and fill 2 fully threaded 3.5 lag screws across the arthrodesis
site. Both screws had excellent purchase and compressed the joint nicely. I
then made a stab incision on the lateral border of the calcaneus and bluntly
dissected down to bone with a snap. I then used the 3.5 drill guide as a
trephine to remove cancellous bone from the calcaneus. I then packed the
cancellous bone into the arthrodesis site.
I next turned my attention to the second metatarsal. I made dorsal incision
over the second MTP joint. Skin and soft tissues were carefully dissected
avoiding any neurovascular structures. EDL tendon was identified, protected and
retracted throughout the entirety of the case. I incised the capsule in line
with the skin incision. I released the capsule medially and laterally and
performed a capsulorrhaphy. This released the contracture. I then visualized
the second metatarsal head and then used a sagittal saw to perform a Weil type
shortening osteotomy. Once I repositioned metatarsal head proximally, I held
the reduction provisionally with a K-wire and then I confirmed fluoroscopically
that the level of the second metatarsal head was just slightly longer than the
first metatarsal head. This was much improved from his preoperative imaging,
which showed him to be at least 5 mm long than his first metatarsal. I then
proceeded to drill, measure and fill a single 2.0 mm lag screw across the
osteotomy. This had excellent purchase and held the reduction nicely.
I then copiously irrigated all wounds with normal saline. Soft tissues were
closed with 2-0 Vicryl, 4-0 Vicryl and 4-0 nylon. Xeroform and dry sterile
dressing was applied after tourniquet was deflated and a well-padded posterior
sugar-tong splint was applied to the left lower extremity. The patient was
awakened from anesthesia and brought to recovery room in stable condition.
Here is the op-note we billed 28730,TA 28308,T1 28270,T1 and 20900 and only received payment for 28730,TA.
We will add modifier 59 on the 28308 that is a separate toe, my question is should we also be paid for the 28270 or is it included in the 28308?
Any help or suggestion with this will be much appreciated. Thank you
PROCEDURES:
1. Left first tarsometatarsal arthrodesis.
2. Left second metatarsal shortening osteotomy.
3. Left second metatarsophalangeal joint capsulorrhaphy and release.
4. Calcaneal bone graft auto harvest.
5. Use of an interpretation of fluoroscopic images of the foot.
COMPLICATIONS: None.
CONDITION: Stable to recovery room.
The patient was brought to the operating room where he was placed supine on the
OR table. Left lower extremity was prepped and draped in the usual sterile
fashion. Timeout was conducted to confirm the correct patient, site and side of
surgery. Perioperative antibiotics were given in the form of Kefzol IV.
Left lower extremity was exsanguinated with an Esmarch and the Esmarch was used
as a tourniquet about the ankle, which was well padded with Webril. I utilized
a dorsal approach to the first TMT joint. Skin and soft tissues were carefully
dissected avoiding any neurovascular structures. EHL tendon was identified,
protected and retracted throughout the entirety of the case. A capsule was
incised in line with the skin incision. I encountered hypertrophic osteophyte
formation on the dorsal aspect of the first TMT joint, which was removed with a
rongeur. I was able then to examine the joint, which showed arthrosis with full
thickness cartilage loss, periarticular sclerosis and osteophyte formation.
I used a combination of osteotomes and a sagittal saw to resect the remaining
articular surface of the joint. I then penetrated the subchondral bone,
fenestrated with the 0.062 K-wire multiple times to prepare for fusion. I then
roughened up the articular surfaces with a Hoke osteotome. I then effected
reduction opposing the 2 articular surfaces together with crossing 0.062
K-wires. After I was happy with the position of the arthrodesis, I proceeded to
drill, measure and fill 2 fully threaded 3.5 lag screws across the arthrodesis
site. Both screws had excellent purchase and compressed the joint nicely. I
then made a stab incision on the lateral border of the calcaneus and bluntly
dissected down to bone with a snap. I then used the 3.5 drill guide as a
trephine to remove cancellous bone from the calcaneus. I then packed the
cancellous bone into the arthrodesis site.
I next turned my attention to the second metatarsal. I made dorsal incision
over the second MTP joint. Skin and soft tissues were carefully dissected
avoiding any neurovascular structures. EDL tendon was identified, protected and
retracted throughout the entirety of the case. I incised the capsule in line
with the skin incision. I released the capsule medially and laterally and
performed a capsulorrhaphy. This released the contracture. I then visualized
the second metatarsal head and then used a sagittal saw to perform a Weil type
shortening osteotomy. Once I repositioned metatarsal head proximally, I held
the reduction provisionally with a K-wire and then I confirmed fluoroscopically
that the level of the second metatarsal head was just slightly longer than the
first metatarsal head. This was much improved from his preoperative imaging,
which showed him to be at least 5 mm long than his first metatarsal. I then
proceeded to drill, measure and fill a single 2.0 mm lag screw across the
osteotomy. This had excellent purchase and held the reduction nicely.
I then copiously irrigated all wounds with normal saline. Soft tissues were
closed with 2-0 Vicryl, 4-0 Vicryl and 4-0 nylon. Xeroform and dry sterile
dressing was applied after tourniquet was deflated and a well-padded posterior
sugar-tong splint was applied to the left lower extremity. The patient was
awakened from anesthesia and brought to recovery room in stable condition.