Question This one has me stumped. Help please!

[dsibley67]

This op note has me stumped. The physician wants to code it as a 28299. I don't see any bone work being done. All I see is the TightRope work. I am leaning toward 28238 & 28313, but I would like a second opinion. Any help will be greatly appreciated.

POSTOPERATIVE DIAGNOSIS: Hallux varus, 22-modifier.
PROCEDURES PERFORMED: Correction hallux varus with modified McBride soft tissue release
and TightRope insertion, left, revision work extra time 22-modifier.
PROCEDURE IN DETAIL: The patient was identified and placed on the treatment table in supine
position. Following general endotracheal intubation, left foot was scrubbed, prepped and draped in usual
aseptic manner. Attention directed to prior cicatrix as this was prior procedure done years ago and the
patient developed hallux varus. Two converging semi-elliptical incisions were used for over the prior
cicatrix and removed from the field in its entirety. Soft tissue released down to the scar tissue from medial
and lateral joint. We did a medial open capsulorrhaphy to assist with decompression of the medial pole.
We found the abductor fascia and distal abductor insertion and released it down to the medial portion just
dorsal to the medial sesamoid. The toe floated in more corrected anatomic alignment at this point.
Attention was directed to the interspace where soft tissues were released around the lateral capsule.
Tightening of lateral capsule gently performed with 2-0 Vicryl. We then did retention of a TightRope
through K-wire and drill hole from distal medial on the proximal phalanx exiting proximal lateral on the
distal phalanx and then reentering the distal lateral portion of first met head, exiting proximal medial to the
metadiaphyseal junction of first metatarsal. Button was then reinserted over the suture from the medial
aspect of the TightRope on the first metatarsal. Toe was floated in a more corrected anatomic alignment
retained. We challenged the foot to move back in varus through pressure and weightbearing and tightened
the TightRope on the button of the medial first metatarsal. Overcorrection was prohibited by allowing
small lateral movement in the first metatarsal and first metatarsophalangeal joint, tightening the TightRope,
however prevented any retention and kept the toe vertical versus varus. TightRope was cut at this point.
We irrigated with normal sterile saline, closed the periosteal layer with 2-0 Vicryl, subcutaneous stitch with
3-0 Vicryl and skin closed with 4-0 nylon. X-rays were taken during the course to visualize angle and
button placement which was excellent.

 

[Orthocoderpgu]

This op note has me stumped. The physician wants to code it as a 28299. I don't see any bone work being done. All I see is the TightRope work. I am leaning toward 28238 & 28313, but I would like a second opinion. Any help will be greatly appreciated.

POSTOPERATIVE DIAGNOSIS: Hallux varus, 22-modifier.
PROCEDURES PERFORMED: Correction hallux varus with modified McBride soft tissue release
and TightRope insertion, left, revision work extra time 22-modifier.
PROCEDURE IN DETAIL: The patient was identified and placed on the treatment table in supine
position. Following general endotracheal intubation, left foot was scrubbed, prepped and draped in usual
aseptic manner. Attention directed to prior cicatrix as this was prior procedure done years ago and the
patient developed hallux varus. Two converging semi-elliptical incisions were used for over the prior
cicatrix and removed from the field in its entirety. Soft tissue released down to the scar tissue from medial
and lateral joint. We did a medial open capsulorrhaphy to assist with decompression of the medial pole.
We found the abductor fascia and distal abductor insertion and released it down to the medial portion just
dorsal to the medial sesamoid. The toe floated in more corrected anatomic alignment at this point.
Attention was directed to the interspace where soft tissues were released around the lateral capsule.
Tightening of lateral capsule gently performed with 2-0 Vicryl. We then did retention of a TightRope
through K-wire and drill hole from distal medial on the proximal phalanx exiting proximal lateral on the
distal phalanx and then reentering the distal lateral portion of first met head, exiting proximal medial to the
metadiaphyseal junction of first metatarsal. Button was then reinserted over the suture from the medial
aspect of the TightRope on the first metatarsal. Toe was floated in a more corrected anatomic alignment
retained. We challenged the foot to move back in varus through pressure and weightbearing and tightened
the TightRope on the button of the medial first metatarsal. Overcorrection was prohibited by allowing
small lateral movement in the first metatarsal and first metatarsophalangeal joint, tightening the TightRope,
however prevented any retention and kept the toe vertical versus varus. TightRope was cut at this point.
We irrigated with normal sterile saline, closed the periosteal layer with 2-0 Vicryl, subcutaneous stitch with
3-0 Vicryl and skin closed with 4-0 nylon. X-rays were taken during the course to visualize angle and
button placement which was excellent.

Personally, I have not seen this exact situation before. Your provider has chosen the incorrect code. 28299 is for two osteotomies which was not done. Surprisingly code 28313 actually works and supports the diagnosis. The other situation is the -22 modifier. As documented it is not supported. Due to prior surgery encounters the provider may have to deal with scar tissue, adhesions and other possible abnormalities. These may be a "bump in the road" or a major hurdle to overcome. Which was it in this case? We don't know because the documentation is not clear. How much extra work was done? How much extra time was taken? Who knows. With this documentation I would not expect the insurance to pay an additional amount. As I see it the tightrope procedure is not separately reportable. This is part of treating the bunion and was done just to keep the toe in place. Frequently a wedge osteotomy is performed for this (28310) which is listed as a "separate procedure".

 

[dsibley67]

Personally, I have not seen this exact situation before. Your provider has chosen the incorrect code. 28299 is for two osteotomies which was not done. Surprisingly code 28313 actually works and supports the diagnosis. The other situation is the -22 modifier. As documented it is not supported. Due to prior surgery encounters the provider may have to deal with scar tissue, adhesions and other possible abnormalities. These may be a "bump in the road" or a major hurdle to overcome. Which was it in this case? We don't know because the documentation is not clear. How much extra work was done? How much extra time was taken? Who knows. With this documentation I would not expect the insurance to pay an additional amount. As I see it the tightrope procedure is not separately reportable. This is part of treating the bunion and was done just to keep the toe in place. Frequently a wedge osteotomy is performed for this (28310) which is listed as a "separate procedure".

So would you only bill the 28313 for this procedure?

 

[Orthocoderpgu]

So would you only bill the 28313 for this procedure?

Yes, but I would speak to the provider about updating the documentation so modifier -22 can be billed. Keep in mind that it may or may not be paid. But right now there is no way it could be.