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Modified Mau Osteotomy

  1. #1
    Default Modified Mau Osteotomy
    Exam Training Packages
    Hi all,
    Does anyone know what CPT code to use for this procedure? My surgeon wants to bill 28292 and 28296, which according to guidelines cannot be billed together. Any suggestions would be appreciated!

    Judith L. Doss, CPC
    OAD Orthopaedics

  2. #2
    Default
    Quote Originally Posted by judithdoss View Post
    Hi all,
    Does anyone know what CPT code to use for this procedure? My surgeon wants to bill 28292 and 28296, which according to guidelines cannot be billed together. Any suggestions would be appreciated!

    Judith L. Doss, CPC
    OAD Orthopaedics
    I would need to see the notes.
    Chastity Nault, CPC
    HIM Professional Services Coder - Remote

  3. #3
    Default Modified Mau Osteotomy
    Cecily,
    Here is the op note:

    An incision was created within the first webspace. Sharp dissection was used to get through skin only. Hemostasis was obtained with electrocautery. Tenotomy scissors were then used to bluntly dissect down into the first webspace. The abductor tendon was identified inserting on the lateral sesamoid. This was then elevated off of the sesamoid from distal to proximal while the assistant was retracting and placing tension on the tendon. The sesamoid was noted to be laterally subluxed from underneath the first metatarsal head.

    Next, a longitudinal incision was created over the medial aspects of the first MTP and extended down the shaft of the first metatarsal. Sharp dissection was used to get through skin and subcutaneous tissue. Hemostasis was obtained with electrocautery. Full thickness skin flaps were created, both dorsally and plantarly around the first metatarsal head. This exposed the first metatarsal phalangeal joint capsule. A longitudinal incision was created within the joint capsule. Synovial tissue was freed both dorsally and plantarly around the first metatarsal head. This exposed the medial eminence. A sagittal saw was then used to remove the medial eminence just medial to the sagittal sulcus.

    Next, the lateral release was then completed with a lateral capsulotomy of the first MTP joint. This adequately freed the toe and allowed appropriate positioning.

    Next, a modified Mau osteotomy was performed with a sagittal saw of the first metatarsal. Osteotome was used to free up the osteotomy. Next, the metatarsal head was then deviated laterally. The osteotomy was then held in place with a bone reducing forceps. The correction was checked with AP and lateral C-arm fluoroscopic images. This was deemed to be appropriate. It corrected the intermetarsal angle as well as the hallux valgus angle.

    Next, a 1.8 mm. drill was used to create a pilot hole from dorsal to plantar within the first metatarsal across the osteotomy site. This was over-drilled with a 2.4 drill. A 2.4 mm. cortical lag screw was then inserted through the pilot hole. Excellent compression was obtained. Another 2.4 mm. cortical lag screw was placed slightly distal to the first one. The length as well as the position of the osteotomy was checked with standard intra-operative ap and lateral C-arm fluoroscopic images.

    An elliptical incision was made directly over the PIP joint of the second toe. This was taken all the way down through the extensor hood. The collateral ligaments of the PIP joint were elevated, both medially and laterally. The condyle of the proximal phalanx was exposed. A saw was used to remove the condyles of the proximal phalanx of the second toe. A rongeur was used to remove the cartilage from the middle phalanx of the toe. Appropriate soft tissue tension was obtained.

    Next, through the first webspace incision, the extensor tendon of the second toe was identified. This was Z-lengthened. This exposed the MTP joint capsule. The joint capsule was incised and freed circumferentially down to the plantar plate. This allowed appropriate correction of the second hammertoe. Next, a 0.054 K-wire was inserted from a retrograde/antegrade fashion through the PIP joint. The second MPT joint was reduced and the wire was advanced across the second MTP joint.

    Next, the abductor tendon that was previously released was sewn into the periosteum of the first and second metatarsal to reinforce the bunion repair.

    Next, all the wounds were thoroughly irrigated with sterile saline solution.

    Final intra-operatvie ap and lateral C-arm fluoroscopic images confirmed the position and correction of the hallux valgus deformity as well as the position and correction of the second hammertoe. The medial capsule was then closed with interrupted 2-0 Vicryl suture. The subcutaneous tissue was also closed with interrupted 2-0 Vicryl suture. The skin on all the incisions was closed in the standard layered fashion with 3-0 Vicryl as well as 4-0 nylon suture. A well-padded bunion wrap was applied to the right foot. A pin protector was placed over the K-wire. The tourniquet was deflated. There was appropriate vascularity with good capillary refill to all of the toes.

    She was awakened by the anesthesiologist, placed supine onto a hospital stretcher and taken to the Recovery Room in stable condition.

    At the end of the case, all sponge and needle counts were correct.

    Thanks,
    Judy

  4. #4
    Default
    Quote Originally Posted by judithdoss View Post
    Cecily,
    Here is the op note:

    An incision was created within the first webspace. Sharp dissection was used to get through skin only. Hemostasis was obtained with electrocautery. Tenotomy scissors were then used to bluntly dissect down into the first webspace. The abductor tendon was identified inserting on the lateral sesamoid. This was then elevated off of the sesamoid from distal to proximal while the assistant was retracting and placing tension on the tendon. The sesamoid was noted to be laterally subluxed from underneath the first metatarsal head.

    Next, a longitudinal incision was created over the medial aspects of the first MTP and extended down the shaft of the first metatarsal. Sharp dissection was used to get through skin and subcutaneous tissue. Hemostasis was obtained with electrocautery. Full thickness skin flaps were created, both dorsally and plantarly around the first metatarsal head. This exposed the first metatarsal phalangeal joint capsule. A longitudinal incision was created within the joint capsule. Synovial tissue was freed both dorsally and plantarly around the first metatarsal head. This exposed the medial eminence. A sagittal saw was then used to remove the medial eminence just medial to the sagittal sulcus.

    Next, the lateral release was then completed with a lateral capsulotomy of the first MTP joint. This adequately freed the toe and allowed appropriate positioning.

    Next, a modified Mau osteotomy was performed with a sagittal saw of the first metatarsal. Osteotome was used to free up the osteotomy. Next, the metatarsal head was then deviated laterally. The osteotomy was then held in place with a bone reducing forceps. The correction was checked with AP and lateral C-arm fluoroscopic images. This was deemed to be appropriate. It corrected the intermetarsal angle as well as the hallux valgus angle.

    Next, a 1.8 mm. drill was used to create a pilot hole from dorsal to plantar within the first metatarsal across the osteotomy site. This was over-drilled with a 2.4 drill. A 2.4 mm. cortical lag screw was then inserted through the pilot hole. Excellent compression was obtained. Another 2.4 mm. cortical lag screw was placed slightly distal to the first one. The length as well as the position of the osteotomy was checked with standard intra-operative ap and lateral C-arm fluoroscopic images.

    An elliptical incision was made directly over the PIP joint of the second toe. This was taken all the way down through the extensor hood. The collateral ligaments of the PIP joint were elevated, both medially and laterally. The condyle of the proximal phalanx was exposed. A saw was used to remove the condyles of the proximal phalanx of the second toe. A rongeur was used to remove the cartilage from the middle phalanx of the toe. Appropriate soft tissue tension was obtained.

    Next, through the first webspace incision, the extensor tendon of the second toe was identified. This was Z-lengthened. This exposed the MTP joint capsule. The joint capsule was incised and freed circumferentially down to the plantar plate. This allowed appropriate correction of the second hammertoe. Next, a 0.054 K-wire was inserted from a retrograde/antegrade fashion through the PIP joint. The second MPT joint was reduced and the wire was advanced across the second MTP joint.

    Next, the abductor tendon that was previously released was sewn into the periosteum of the first and second metatarsal to reinforce the bunion repair.

    Next, all the wounds were thoroughly irrigated with sterile saline solution.

    Final intra-operatvie ap and lateral C-arm fluoroscopic images confirmed the position and correction of the hallux valgus deformity as well as the position and correction of the second hammertoe. The medial capsule was then closed with interrupted 2-0 Vicryl suture. The subcutaneous tissue was also closed with interrupted 2-0 Vicryl suture. The skin on all the incisions was closed in the standard layered fashion with 3-0 Vicryl as well as 4-0 nylon suture. A well-padded bunion wrap was applied to the right foot. A pin protector was placed over the K-wire. The tourniquet was deflated. There was appropriate vascularity with good capillary refill to all of the toes.

    She was awakened by the anesthesiologist, placed supine onto a hospital stretcher and taken to the Recovery Room in stable condition.

    At the end of the case, all sponge and needle counts were correct.

    Thanks,
    Judy
    Based on the OP note, I would use 28299 (Double Osteotomy).

    28299 Hallux valgus (bunion) correction, with or without sesamoidectomy; by other
    methods (eg, double osteotomy)

    With severe hallux valgus or a congruent joint, a double ostestomy of the first
    metatarsal or metatarsal and proximal phalanx might be required.

    Now, I did this as quickly as possible, so I hope that I am correct.
    Chastity Nault, CPC
    HIM Professional Services Coder - Remote

  5. Default
    I don't see where it states you cannot bill these 2 procedures together. It is not Modifier 51 exempt, which is how I might suggest billing the 28296, with the 51. If anything, you would just get a denial stating it's not billable together for whatever reason.

  6. #6
    Default Modified Mau Osteotomy
    He wants to bill:
    28292
    28296
    28285
    28270-59

    I asked him to change the 28292 and 28296 to 28299, but his response was that he did not do a double osteotomy. Upon, review of the op note I agree with him.

    Judy

  7. #7
    Default
    Quote Originally Posted by CLREECE View Post
    I don't see where it states you cannot bill these 2 procedures together. It is not Modifier 51 exempt, which is how I might suggest billing the 28296, with the 51. If anything, you would just get a denial stating it's not billable together for whatever reason.
    I don't see where it states that this was a Joplin Procedure.
    Chastity Nault, CPC
    HIM Professional Services Coder - Remote

  8. #8
    Default
    Quote Originally Posted by judithdoss View Post
    He wants to bill:
    28292
    28296
    28285
    28270-59

    I asked him to change the 28292 and 28296 to 28299, but his response was that he did not do a double osteotomy. Upon, review of the op note I agree with him.

    Judy
    I agree with what he wants to bill. I'm just not sure about that modifier on procedure 28270. It says that it's a separate procedure, so why would you need it?
    Chastity Nault, CPC
    HIM Professional Services Coder - Remote

  9. #9
    Default Modified Mau Osteotomy
    Need the 59 modifier because it is bundled with 28292.

    Judy

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