August 2002 Bulletin

Bunionectomy codes

Selecting the right ones for a toe/foot procedure is key

By Margie Scalley Vaught, CPC, CCS-P, MCS-P and reviewed by Walter J. Pedowitz, MD

How do you know what CPT codes match the type of procedures being performed on the feet? Which of the eight bunionectomy codes (28290—28299) match what is actually being done? Can you code more than one procedure per toe/foot on the same date of service? What modifiers should be used?

On a daily basis, these questions and many more are asked when coders/billers/ surgeons try to select the correct code for the feet procedures being performed. This article will shed some light on the CPT codes, what they represent and tips in selecting the most appropriate based on documentation supplied.

Bunionectomy codes

Each bunionectomy code has the same "root" procedure, which is "Correction, hallux valgus (bunion), with or without sesamoidectomy;" where they differ is the descriptions after the semi-colon. Since each bunionectomy code describes the correction of the bunion, the actual way that the bunion is being corrected is where we will need to focus. Keep in mind that "eg" is just an example and NOT all-inclusive. There are many different names associated with bunionectomy procedures. The important part is linking the type of bunion procedure with the appropriate bunion code listed in the CPT manual.

28290 – ; simple exostectomy This procedure is just that—a simple exostectomy.
AAOS states that this procedure includes: arthrotomy, synovial biopsy, extensor tenotomy, synovectomy, capsular release and reconstruction, removal of additional exostoses in the area of that joint, internal fixation, articular shaving, arthroscopy, removal of bursal tissue, excision of redundant skin and closure, capsular arthroplasty, excision of bone or synovial cysts and allows additional coding and report for: phalangeal osteotomy to correct deformity, proximal first metatarsal osteotomy and ankle tendon lengthening.

28292 - ; Keller, McBride or Mayo type procedures These particular procedures involve a distal soft tissue release (McBride), a resection of the base of the proximal phalanx (Keller), or a resection of the metatarsal head (Mayo). AAOS states that this procedure includes: arthrotomy, synovial biopsy, tendon release or transfer, synovectomy, capsular release and reconstruction, removal of additional exostoses in the area of that joint, internal fixation, articular shaving, arthroscopy, removal of bursal tissue, repair of released tendon, capsular arthroplasty, first metatarsal head resection and excision of bone or synovial cysts and allows additional coding and report for: phalangeal osteotomy to correct deformity, proximal first metatarsal osteotomy and ankle tendon lengthening.

28293 - ; resection of joint with implant (Keller-Mayo Procedure with implant) This procedure involves resection of all or half of the metatarsophalangeal joint with the insertion of a double or single stemmed implant. AAOS states that this procedure includes: arthrotomy, synovial biopsy, tendon release or transfer, synovectomy, capsular release and reconstruction, removal of additional exostoses in the area of that joint, internal fixation, arthroscopy, removal of bursal tissue, repair of released tendon, excision of bone or synovial cysts, removal of first metatarsophalangeal joint, and all types of implants and implant fixation and allows additional coding and reports for: phalangeal osteotomy to correct deformity, proximal first metatarsal osteotomy and ankle tendon lengthening.

28294 - ; with tendon transplants (e.g. Joplin type procedure) This procedure includes tendon transplants. AAOS states that this procedure includes: arthrotomy, synovial biopsy, tendon transfer, synovectomy, capsular release and/or reconstruction, removal of additional exostoses in the area of that joint, articular shaving, removal of bursal tissue, repair of released tendon, tenotomy, extensor tendon, tendon transfer, tendon repair and allows additional coding and report for: phalangeal osteotomy to correct deformity.

28296 - ; with metatarsal osteotomy (e.g. Mitchell, Chevron or concentric type procedures) This procedure includes a distal metatarsal osteotomy. AAOS states that this procedure includes: arthrotomy, synovial biopsy, tendon release or transfer, synovectomy, capsular release and reconstruction, removal of additional exostoses in the area of the joint, internal fixation, articular shaving, arthroscopy, removal of bursal tissue, repair of released tendon, implant insertion, local bone graft and allows additional coding and report for: phalangeal osteotomy to correct deformity, harvesting and insertion of bone graft from distant site (separate skin or fascial incision), and ankle tendon lengthening.

28297 - ; Lapidus type procedure This procedure is a distal soft tissue rearrangement and a proximal first metatarsal cunieform arthrodesis. AAOS states that this procedure includes: arthrotomy, tendon transfer or release, synovectomy, capsular release and/or reconstruction, removal of additional exostoses in the area of the joint, internal fixation, removal of bursal tissue, repair of released tendon, arthrodesis, tarsometatarsal joint, local bone graft, proximal first metatarsal osteotomy and allows additional coding and report for: phalangeal osteotomy to correct deformity, harvesting and insertion of bone graft from distant site (separate skin or fascial incision) and ankle tendon lengthening.

28298 - ; by phalanx osteotomy This procedure includes a proximal phalanx osteotomy of the great toe. AAOS states that this procedure includes: arthrotomy, synovial biopsy, synovectomy, capsular release and/or reconstruction, removal of additional exostoses in the area of the joint, internal fixation, removal of bursal tissue, local bone graft, excision of bone or synovial cysts, partial excision of metatarsal and allows additional coding and report for: proximal first metatarsal osteotomy, distal first metatarsal osteotomy, ankle tendon lengthening.

28299 - ; by double osteotomy There are two techniques described in the CPT book. One includes a proximal and distal osteotomy of the first metatarsal. The other example includes a distal osteotomy of the first metatarsal plus a base osteotomy of the attached proximal phalanx. AAOS states that this procedure includes: any combination of hallux valgus procedures (e.g. 28290-28298, 28485), includes all osteotomies of the first metatarsal and first proximal phalanx and allows additional coding and report for ankle tendon lengthening.

Osteotomy Codes

Osteotomy is a surgical procedure that changes the alignment of a bone with or without removal of a portion of that bone. It may be considered for correction of a malaligned fracture, osteoarthritis or other joint conditions. Many of the above bunionectomy procedures allowed additional billing and reimbursement for several different osteotomy procedures, such as CPT codes 28306, 28307 and 28310. These procedures are described below.

28306—Osteotomy, with or without lengthening, shortening or angular correction, metatarsal; first metatarsal.

28307—Osteotomy, with or without lengthening, shortening or angular correction, metatarsal; first metatarsal with autograft (other than first toe).

28310—Osteotomy, shortening, angular or rotational correction; proximal phalanx, first toe (separate procedure).

Reporting procedures

When reporting the above procedures along with a bunion procedure, you will need to make sure that a modifier is appended, such as modifier -59 to indicate that these osteotomy procedures are above and beyond those procedure necessary to perform this coded bunionectomy and are performed at a separate site or through a separate incision. If you are also performing hammertoe repairs on different toes at the same time as a bunion procedure, you will want to make sure that you append the appropriate toe modifiers to indicate that the procedures are taking place on different toes.

If the surgeon is also performing excisions of neuromas or other procedures that are separate and distinct from the bunionectomy procedure and not considered by the AAOS to be bundled into that bunion approach, you need to make sure that you append the modifier –59 to alert the carriers to the fact that these additional procedures are just that, separate and distinct. Documentation in the operative note needs to support the classification that these are indeed separate and distinct from the major procedure.

Ostectomy Codes

Ostectomy means removal of a portion of bone. Excision codes can include ostectomy codes, not to be confused with osteotomy codes. These codes consist of excising bony prominences or sections of bone either partial or complete.

28110—Ostectomy, partial excision, fifth metatarsal head (bunionette) (separate procedure).

28111—Ostectomy, complete excision; first metatarsal head.

28112—Ostectomy, complete excision; other metatarsal head (second, third or fourth).

28113—Ostectomy, complete excision; fifth metatarsal head.

28114—Ostectomy, complete excision; all metatarsal heads, with partial proximal phalangectomy, excluding first metatarsal (eg, Clayton type procedure).

28288—Ostectomy, partial, exostectomy or condylectomy, metatarsal head, each metatarsal head.

Reporting procedures

When reporting the above procedures along with a bunion procedure, you will need to make sure that a modifier is appended, such as modifier -59 to indicate that these ostectomy procedures are above and beyond those procedure necessary to perform this coded bunionectomy and are performed at a separate site or through a separate incision.

Modifiers

CPT has listed and identified toe modifiers that can be applied when performing surgery on different toes. These modifiers are:

T1–Left foot, second digit

T2–Left foot, third digit

T3–Left foot, fourth digit

T4–Left foot, fifth digit

T5–Right foot, great toe

T6–Right foot, second digit

T7–Right foot, third digit

T8–Right foot, fourth digit

T9––Right foot, fifth digit

TA–Left foot, great toe

Some tips, teamwork and internal policies

A great tip in coding bunionectomies is to actually take a look at the codes currently allowed by CPT and find the one that fits the technique the surgeon is doing. Many offices have found that making copies of the actual CPT pages and providing the information to the surgeon is helpful to start the dialog and communication process going.

Foot and toe coding take teamwork and can at times encompass a great deal of surgeon involvement. Set up internal policies related to coding feet procedures by surgeon if you need to. Just as hospitals have "preference cards" alerting the hospital surgical crew as to what a particular surgeon "prefers" or needs for a certain procedure so that policies can be developed and updated to help assist in correct coding of procedures performed by surgeons. Surgeons usually do not learn CPT language and descriptions as part of their medical training so many times their narrative descriptions do not say the same exact wording as CPT, but are indeed referring to the same procedure performed. Have access to medical publications relating to feet procedures. Many surgeons have these books in their libraries that can be referenced for clarification. Understand the anatomy of the foot and the terminology associated with the feet.

With understanding and team effort, coding and billing for feet procedures can be taken out of the ‘unknown’ and dreadful stack and placed into the ‘understanding’ and completed stack.

References:

CPT 2002 Professional Edition, American Medical Association

A Manual of Orthopaedic Terminology, 6th Edition, Blauvelt and Nelson

The American Illustrated Medical Dictionary, 29th Edition, Dorland

AAOS Complete Guide to Global Service Data, 2002 edition

Margie Scalley Vaught, CPC, CCS-P, MCS-P, is an independent coding specialist in Ellensburg, Wash. She is also a member of the American Academy of Professional Coders’ National Advisory Board. She can be reached at vaught@kvalley.com.

Walter J. Pedowitz, MD, is a foot and ankle specialist at the Union County Orthopedic Group in Linden, N.J., and a clinical professor of orthopaedic surgery at Columbia University in New York. He is also a member of the AAOS CPT and ICD coding committee. He can be reached at (908) 486-1111 or at ped4feet@comcast.net.

Answers to common coding questions may be affressed in future editions fo the Bulletin. Fax (847) 823-8026.


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