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!
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