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Exostosis confusion and podiatry coding confusion

  1. Default Exostosis confusion and podiatry coding confusion
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    Please help - any thoughts would be appreciated! Here's an op note:

    ..".Attention was directed to the dorsum of the right mid foot in between the tibialis anterior tendon and EDL tendon along the lateral margin of the tibialis anterior tendon. Subcutaneous tissues were dissected. Longitudinal capsulotomy subperiosteal dissection was done at the second cuneiform metatarsal base and proximal to this. What appeared to be a traumatic neuroma appeared. This was excised. Some of the deep subfascial tissues were collected and labeled neuroma, deep cyst, right foot. The tibialis anterior tendon sheath had no longitudinal splits and the area appeared helathy. The tendon sheath did have some fibrillation, which was debrided and subsequently repaired utilizing 2-0 Vicryl stitch. Prior to the tendon repair, sagittal saw and hand rasp was done to debulk the area dorsally where the exostosis was. Forefoot was loaded and no bony prominences remained. Bone wax was applied following irrigation utilizing sterile saline solution. Bone wax was fitted. Tibialis anterior tendon sheath was repaired utilizing 2-0 Vicryl stitch, reinforced with 2-0 silk, subcu 3-0 Vicryl, skin 4-0 nylon............"

    28080 for the neuroma .... but can I also code for a tarsal exostectomy...but it was all done through the same incision....??? The path report was just the neuroma so there was no 'bone cyst or benign tumor' that was turned in. So- if I CAN code additionally for the exostectomy.... I've read so many conflicting reports about the cpt to use...some people say if it's just documented as exostosis, to use the 'bone cyst or benign tumor' 28104 - but some people say if it's not documented as a 'bone cyst or benign tumor', you can't use the 28104, you should use the 28122 - the partial excision of bone.

    Any thoughts on this would be greatly appreciated!

  2. #2
    I would use the 28122- I was taught "bossing" is same as exostosis.

    You will have to pick your codes- then look to see if codes are included with each other(under medicare or commercial)

    my orthopaedic dictionary definition for bossing (28122) is "rounded prominence of bone that is abnormally visible under the skin" - exostosis "excess bone formation"

    It may not necessarily be "visible" but they are both bony prominences.

    I would think 28122 would be most appropriate, I would not code something the doc specifically says is an exostosis, as a tumor or cyst.

    Sounds good right?

  3. Default
    Thank you for your thoughts. Seeeee - that's what I always thought, too. Exostosis is NOT the same as a bone cyst/benign tumor. I read somewhere years ago the same thing you mentioned - 'bossing' should point you to 'removal of bone or excess bone' as in 'part of the bone' as in 28122.

    BUT - look at the CPT section for leg and ankle joints.

    Underneath 27640 and 27641, there's a highlighted note under each one of those codes that reads: "For exostosis excision, use 27635." And 27635 is - you guessed it - "excision or curettage of bone cyst or benign tumor"

    So - I'm still wondering.

  4. #4
    I am going to go ahead and assume this is because the leg does not have specific codes to address these types of problems, as the foot does. I work with pods and orthos and I almost never see an exostosis of the leg, every once in a while I will see one on the prox tib. so I think they just do not have specific codes in leg???

  5. #5
    I know this is just a tad late but in 2010 coding for exostosis removal changed to those in the bone cyst range.

  6. Smile
    Oh no - never 'late' with additional information!

    I know that in 2010 the 27640 (tibia) and 27641 (fibula) 'partial excision of bone' codes acquired the notes below them to point you to 27635 - 'bone cyst or benign tumor' - for exostosis excision of the tibia or fibula.

    However, there are no such pointers underneath the 'partial excision of bone' codes in the foot codes.....

    Do you know of any references that state this specifically for exostosis excision for the feet?

    Thanks for your help.

  7. Default
    I know this is late as well.... but this is very interesting because certain audit companies like TCN network are also stating this ....exostosis... code bone cyst/tumor exicision codes according to AMA, but I've never actually seen an article of any such thing from anywhere?

  8. Smile
    Thank you all for your thoughts and input.

    BFaithful - can you ask whoever was doing the TCN audit to supply some written documentation that says the AMA said that? That the exostosis removal should be coded with the 'bone cyst' removal code? Does the documentation then state the conditions -if any - where you would switch to the 'partial removal of bone' codes versus the bone cyst codes? At what point -and how would it be documented - does bossing off an exostosis not include shaving off some bone (ie - 'bone removal')along with it?

    The 'coding buddhas' I've thrown this at say the same thing as Plaidman said above ...I can't assume anything from 'coding in another part of the body' - just because CPT directs us to use the bone cyst code for removal of exostosis IN THE LEG doesn't mean we should use the bone cyst code for removal of exostosis IN THE FOOT.....especially since the foot has other codes that are more specific (the partial removal of bone.)

    If anyone else sees or hears anything, documentation-wise, I'd sure appreciate seeing it. Thank you all for your knowledge.

  9. Default
    I'm sorry...I can't really do that.. because I only know that TCN states this because if you go to their website they have sample audit reports and in their sample audit reports that what is says about the AMA but I have yet to see such article with my own eyes. I am going to send in my question to the AMA directly and once I receive their response I will get back to you. I have done this in the past where I am really confused about a CPT code.

  10. Smile
    Thank you, Bfaithful - I just found that sample audit you were speaking of - the one where TCN said the wrong code was used for excision of exostosis - 28112 - should have been 28104 -removal of bone cyst or benign tumor....and you're right - they say on that audit 'per the AMA'...... please keep us posted.

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