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IP Fusion of the Left Great Toe - CPT 28285?

  1. Default IP Fusion of the Left Great Toe - CPT 28285?
    Medical Coding Books
    I am brand new to coding foot procedures. My new MD submitted a bill to me for "IP Fusion of the Left Great Toe" - would this fall under 28285?

    From the Op Report:

    HISTORY: A 77-year-old with painful left great toe. She actually had releases of her long flexors of toes 2, 3 and 4, and had done really well, and desired some correction of her claw deformity of her right toe.

    DESCRIPTION OF PROCEDURE: After successful induction, the left lower extremity was prepped and draped. Tourniquet was inflated after gravity exsanguination. I made an incision that started distal medial touring straight transverse across the IP joint and then turning proximally and laterally. We exposed the joint, opened it up. We then took down the distal proximal phalanx, condyles until a flat surface and then the articular and subchondral bone off the distal phalanx to create 2 raw flat surfaces. We advanced pins out the tips of the toe, avoiding any contact with the nail-bed. Then we retrograded these down into the proximal phalanx. We imaged to confirm alignment and then overreamed and placed screws. We had excellent compression to the lateralmost screw and, even though some of the threads appeared to still stay on the distal side, there was such a great purchase and excellent compression that we felt this was an excellent screw. The more medial screw had a lesser fixation, but gave us some manner of rotation and alignment. We removed the pins, closed the skin distally, closed the capsule dorsally and then nylon in the skin. Infiltration of Marcaine 0.25 percent. Xeroform and bulky dressing.

    Plan is to have the patient foot flat weight-bearing in a postop shoe for 6 weeks.

  2. #2
    Take a look at CPT code 28755, this code is for an IP joint arthrodesis, the op note appears to describe this procedure.

  3. #3
    Greater Pittsburgh
    I agree with 28755 for great toe fusion, interphanlangeal joint. OTHER(lesser) toes / fusion interphanlangeal joint would be 28285
    jdemar, CPC, CMA

  4. Default
    Thank you for the input. I appreciate all the help!

  5. Default fusion MTP joint lesser toes
    What code do you use for fusion MTP joint of the lesser toes?

  6. #6
    Greater Pittsburgh
    28112 ( 2nd, 3rd or 4th) or 28113 (5th).
    jdemar, CPC, CMA

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