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Bunion and hammertoe procedures

  1. #1
    Location
    Glesns Falls, NY
    Posts
    16
    Default Bunion and hammertoe procedures
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    Hello fellow codes, coding these procedures for a while and still struggling with multiply procedures performed on one toe, especially the hammertoe. here is one of the OP report.

    I'm thinking of 28297 for Bunion and of course 28285 for hammertoe, anything else? Weil osteotomy always throws me off...PLEASE HELP:

    PREOPERATIVE DIAGNOSIS: Painful bunion right. Hammertoe second right and dislocated second
    metatarsophalangeal joint dorsally on the right.

    POSTOPERATIVE DIAGNOSIS: Painful bunion right. Hammertoe second right and dislocated second
    metatarsophalangeal joint dorsally on the right.

    PROCEDURE:
    1. Lapidus bunionectomy on the right.
    2. Hammertoe correction, arthrodesis second PIPJ right.
    3. Weil osteotomy second metatarsophalangeal joint right.

    OPERATION AND FINDINGS: The patient was brought to the operating room and placed on the
    operating room table in the supine position. Local anesthesia was achieved per
    anesthesiologist with a pop/fos block. The area was then prepped and draped in the usual
    sterile manner. A pneumatic ankle tourniquet was applied to the right ankle. The right foot
    was then elevated and exsanguinated with an Esmarch bandage and the right ankle tourniquet
    was inflated to 250 mmHg.

    Attention was directed to the dorsal aspect of the right foot where a dorsal linear
    incision was made approximately 12 cm in length, extending from the first
    metatarsophalangeal joint to the first metatarsocuneiform joint. The incision was deepened
    via sharp and blunt dissection taking care to retract and identify all vessels and nerves.
    An inverted-L capsulotomy was performed at the first MPJ and the capsule from freed from
    the medial eminence, which was delivered into the wound, noted to be degenerative changes
    noted. Using a power saw the medial eminence was removed and all bony spicules were rasped
    with an electric rasp.

    Attention was then directed to the first interspace where adductor tenotomy and capsulotomy
    was performed.

    Attention was then directed to the first metatarsocuneiform joint, where a linear
    capsulotomy was performed and all capsular tissue was freed from the dorsal, medial and
    lateral aspect. Using an Arthrex retractor, the joint was opened and the cartilage was
    removed off the base of the first metatarsal and along the distal aspect of the cuneiform.
    The IM was reduced and the digit was put in the correct position, temporarily fixated with
    a 62 K-wire and then permanently fixated with an Arthrex Nitinol screw 18 x 18 dorsal
    lateral and a 3.5 Arthrex headless screw dorsal distal to proximal plantar. Noted to be
    good apposition and good alignment. The area was flushed with sterile solution, further
    inspected for debris. When none was found, a capsulorrhaphy was obtained using 3-0 Vicryl.
    Subcu was obtained using 4-0 Vicryl and skin closure was achieved using 4-0 nylon simple
    running interlocking suture. It was noted that after reducing the IM angle, we did not need
    to do an Akin osteotomy. The digit was in the corrected position.

    Attention was then directed to the second digit, where a dorsal linear incision was made
    approximately 8 cm in length extending from the second PIPJ to he second MPJ. The incision
    was deepened via sharp and blunt dissection, taking care to retract and identify all
    vessels and nerves. The incision was deepened to the level of the capsule of the second
    MPJ, where a linear transverse capsulotomy was performed after freeing up the extensor
    tendon hood. Using a power saw, a Weil osteotomy was made dorsal distal to proximal plantar
    and the head was shifted approximately 4 mm proximally and fixated with a 12-mm 2.5 Arthrex
    headless screw. Dorsal to plantar, the osteotomy was stable. The dorsal lip was removed
    with a rongeur and all bony spicules were rasped with an electric rasp.

    Attention was then directed to the second PIPJ where using a Zimmer ToeTac, the cartilage
    was removed using the reamers. The digit was put in the corrected position and the implant
    was put in position as instructed and as procedure. The K-wire was driven, then through the
    implant and into the second MPJ with the digit held in the corrected position.

    The area was flushed with sterile saline solution, further inspected for debris. When none
    was found, deep closure was obtained using 3-0 and 4-0 Vicryl suture and skin closure was
    achieved using 4-0 nylon simple running interlocking sutures, simple interrupted sutures.

  2. #2
    Location
    Salt Lake North
    Posts
    839
    Default I'm not sure that you have the problem you think you do
    The bunion repair is frequently performed at the MTP joint, but the Lapidimus is performed at the midfoot joint instead. 28297.

    However the hammertoe and wiel were performed on the 2nd toe, not the big toe. So there is no bundling issue there, but you do need to use modifiers to show that the hammertoe is not related to the bunion.

    Frequently the wiel is done for metatarsalgia. But I don't see it being done for that reason in this case. I would find out what condition it was treating. It could be part of the hammertoe, but I am not clear on that from the documentation.
    Last edited by Orthocoderpgu; 11-12-2018 at 10:40 AM.

  3. #3
    Location
    Glesns Falls, NY
    Posts
    16
    Default
    Quote Originally Posted by Orthocoderpgu View Post
    The bunion repair is frequently performed at the MTP joint, but the Lapidimus is performed at the midfoot joint instead. 28297.

    However the hammertoe and wiel were performed on the 2nd toe, not the big toe. So there is no bundling issue there, but you do need to use modifiers to show that the hammertoe is not related to the bunion.

    Frequently the wiel is done for metatarsalgia. But I don't see it being done for that reason in this case. I would find out what condition it was treating. It could be part of the hammertoe, but I am not clear on that from the documentation.
    Thank you !

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