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Certificate of Attendance
Advanced Clinic: Bunionectomy CPT Coding
January 15, 2004
_____________________________________
NAME
Lolita M. Jones, RHIA, CCS
Presenter
The American Health Information Management Association (AHIMA) has approved this program for
two (2) continuing education clock hours in the External Forces content area.
Retain this certificate as evidence of participation.
Advanced Clinic:
Bunionectomy CPT Coding
Presenter:
Lolita M. Jones, RHIA, CCS
Lolita M. Jones Consulting Services
1921 Taylor Avenue
Fort Washington, MD 20744
(V) 301-292-8027
(FAX) 301-292-8244
Coding Training: www.hcprofessor.com
E-mail: [email protected]
Distributed by HCPro, Inc.
TABLE OF CONTENTS
I.
II.
III.
Clinical Coder: Skeletal Anatomy of the Foot ........................................................... 9
Bunionectomy: Background...................................................................................... 12
CPT Bunionectomy Codes and Case Studies............................................................. 14
CPT Code 28110 - Ostectomy, partial excision, fifth metatarsal head ....................... 14
(bunionette)
Case Study 1
Case Study 2
CPT Code 28290 - Simple exostectomy/Silver-type procedure ................................. 19
Case Study 3
CPT Code 28292 – Keller......................................................................................... 22
CPT Code 28292 – McBride..................................................................................... 23
CPT Code 28292 – Mayo ......................................................................................... 24
CPT Code 28293 – Resection of joint with implant................................................... 25
CPT Code 28293 – Swanson..................................................................................... 26
Case Study 4
Case Study 5
CPT Code 28294 – Joplin-type procedure (bunion correction with tendon
transplants) ................................................................................. 31
CPT Code 28296 - Mitchell (bunion correction with metatarsal osteotomy).............. 32
Case Study 6
CPT Code 28296 - Chevron (bunion correction with metatarsal osteotomy).............. 35
Case Study 7
CPT Code 28296 – Concentric-type procedure (also called crescentic
osteotomy) (bunion correction with metatarsal osteotomy).......... 37
Case Study 8
CPT Code 28296 – Austin osteotomy & Reverse Austin.......................................... 40
Case Study 9
CPT Code 28297 – Lapidus-type procedure.............................................................. 43
Case Study 10
Case Study 11
CPT Code 28299 - Double Osteotomy ..................................................................... 49
Case Study 12
CPT Code 28750 – First metatarsophalangeal joint arthrodesis
53
Case Study 13
Answer Key
56
Disclaimer
Advanced Clinic: Bunionectomy CPT Coding is designed to provide accurate and authoritative
information in regard to the subject covered. Every reasonable effort has been made to
ensure the accuracy of the information within these pages. However, the ultimate responsibility lies with the user.
Lolita M. Jones Consulting Services and staff make no representation, guarantee or warranty, express or implied, that
this compilation is error-free or that the use of this publication will
prevent differences of opinion or disputes with Medicare or other third-party payers, and
will bear no responsibility or liability for the results or consequences of its use.
Physician’s Current Procedural Terminology, Fourth Edition (CPT-4) is a copyrighted coding system owned and
maintained by the American Medical Association.
Please contact Lolita M. Jones, RHIA, CCS at:
(V) 301-292-8027
(Fax) 301-292-8244
Coding Training: www.hcprofessor.com
E-mail: [email protected]
© 2004 Lolita M. Jones Consulting Services
All five-digit number Physician’s Current Procedural Terminology, Fourth Edition (CPT) codes,
service description, instructions and/or guidelines are 2003 American Medical Association. All
rights reserved.
All rights reserved. The author grants permission for photocopying for limited personal use or
internal use of the original purchaser. This consent does not extend to other kinds of copying, such
as for general distribution, for advertising or promotional purposes, for creating new collective
works, or for resale.
BUNION
Advanced Clinic
Bunionectomy CPT Coding
About Lolita M. Jones Consulting Services
HOSPITAL TRAINING PROGRAMS
Coding Training: www.hcprofessor.com
(V) 301-292-8027
(FAX) 301-292-8244
E-mail: [email protected]
BIOGRAPHY:
Lolita M. Jones, RHIA, CCS, is an independent consultant specializing in hospital outpatient and
ambulatory surgery center coding, billing, reimbursement, and operations. Ms. Jones recently
launched her web-based coding program at www.EZMedEd.com. She has over 15 years of
experience in publishing, training, and auditing for the hospital outpatient and freestanding
ambulatory surgery center (ASC) markets. Ms. Jones has earned both the Registered Health
Information Administrator and Certified Coding Specialist credentials from the American Health
Information Management Association (AHIMA) in Chicago, IL. Ms. Jones resides in Fort
Washington, Maryland, and she has developed six (6) specialty manuals for freestanding
ambulatory surgery centers (ASCs) as well as comprehensive manuals for the following
ambulatory payment classification (APC) training programs:
Basic CPT Outpatient Coding Clinic: This 6.5 hour program is designed for
(Future/Beginning/Current) Coding Specialists, Coding Managers, Reimbursement Specialists,
Compliance Auditors, Hospital-Based Clinic Managers, and ALL hospital staff responsible for
outpatient coding including emergency room, ancillary department and hospital-based clinic staff.
The contents include general guidelines, steps for coding, and official CPT guidelines for surgical
procedures that are commonly performed in the hospital outpatient setting. Exercises based on
actual ambulatory surgery operative reports will be used to strengthen the attendees’ understanding
of the guidelines presented.
APC Institute: Impact on Emergency Services: This 3 hour program is designed for Emergency
Department: Directors, Managers, Supervisors, and Nurses; Registration Staff, Health Information
Managers, Coding Specialists, and Cast Room Technicians.
The contents include APC Grouping Logic, Mapping Logic for ED Medical Visits,
APCs for Emergency Department Services, Modifiers –25 and –27, Emergency Screening without
Treatment, Critical Care, “Clotbuster” Drugs, Tissue Adhesive Wound Closure, and
Documentation Guidelines.
All CPT Codes © 2003 American Medical Association * Lolita M. Jones Consulting Services
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Advanced Clinic
Bunionectomy CPT Coding
APC Institute: Outpatient Compliance Action Plan: This 6.5 hour program is
designed for Compliance Department Staff (Corporate Officers, Directors, Managers,
Analysts, Auditors); Health Information Management Staff (Directors, Coding
Managers/Supervisors, Coding Specialists); Risk Managers, APC Coordinators,
Reimbursement Specialists, Decision Support Analysts, Outpatient Billing Supervisors,
Outpatient Billing Specialists, Software Vendor Product Managers, ALL staff responsible
for facility component outpatient coding in: Registration, Hospital-Based Clinics,
Ancillary Departments, and the Emergency Department. The contents include: Brief
Overview of APCs; CPT Surgery Coding Compliance; and APC Compliance Issues: siteof-service billing, reason for visits, discontinued surgery, medical visits, “limited followup services,” colorectal cancer screening, observation stay without recovery, critical
care, interventional radiology, modifiers, unlisted procedure codes, units of service, UB92 claims data, and higher level APC groups.
APC Institute: Clinical Documentation Strategies: This 6.5 hour program is designed for
nursing, utilization management, case management, and other health care professionals responsible
for health records documentation. The contents include ambulatory payment classification (APC)related clinical documentation requirements and management tips for the following sites of
service: Emergency Room, Observation Beds/Unit, Ambulatory Surgery, Hospital-Based
Outpatient Departments/Clinics, Pain Management Clinic, Series/Recurring Services, Partial
Hospitalization Program, Cast Room, Ancillary Testing Areas, and Utilization Management.
APC Institute: Coding Guidelines for Hospitals - This 1 or 2 day program is designed for all
technical, clinical and managerial staff responsible for facility component outpatient coding that
will directly impact ambulatory payment classification (APC) payments. The contents include:
Ambulatory Surgery Reimbursement under APCs, APC Data Reporting Requirements, Medicare
Hospital Outpatient Edits, Outpatient Billing Procedures and Guidelines, Ambulatory Claims
Rejection Monitors, Peer Review Ambulatory Surgery Review, Coding System Reviews, How to
Use ICD-9-CM, How to Use CPT, and CPT Coding Guidelines By Body System (Integumentary,
Musculoskeletal, Respiratory, Cardiovascular and Lymphatic, Hemic and Lymphatic, Digestive
System, Urinary, Male Genital, Laparoscopy/Hysteroscopy, Female Genital, Endocrine, Nervous,
Eye and Ocular Adnexa, Auditory).
All CPT Codes © 2003 American Medical Association * Lolita M. Jones Consulting Services
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Bunionectomy CPT Coding
Modifier Clinic: Hospital Outpatient Issues: This 6.5 hour program is designed for coding,
reimbursement, compliance, billing, database management, ancillary, and clinic staff responsible
for modifier programming, reporting, billing, and auditing. The contents include: Modifier
Reporting Requirements, Official Medicare Guidelines, Recommended Hospital Front-End
Modifier Edits, Electronic/On-Line UB-92 Reporting of Modifiers, Coding and Billing
Aborted/Discontinued Procedures, ICD-9-CM vs. Medicare Coding Guidelines, Unsuccessful vs.
Aborted/Discontinued Procedures, Documentation of Reduced/Discontinued Procedures, Testing
Potential Coders, Software Encoder Modifier Edits, Interventional Radiology Procedures,
Information System Upgrades, Data Quality Review, Radiology Modifier Reporting Issues,
Ancillary Department Modifier Reporting for Hospitals, and Exercises/Case Studies.
APC Institute: Hospital Financial and Operational Issues: This 6.5 hour program is designed
for hospital executives, directors, chargemaster coordinators, coding/reimbursement staff, and
information system/database managers who will implement ambulatory payment classifications
(APCs). The contents include: General Overview of APCs, APC Data Reporting Requirements,
APC Policy Issues, Developing a Plan of Action, Conducting Hospital-Wide APC Education, and
Assessing Current Outpatient Operations for: Overall Hospital, Management Information Systems,
Business Office/Patient Accounts, Health Information Management, Ancillary
Departments/Chargemaster, Emergency Room, Hospital-Based Clinics, Hospital-Owned Satellite
Facilities, Hospital-Based Physician Coding and Billing, and Utilization Management.
APC Institute: Billing and Reimbursement Issues. This 6.5 hour program is designed for Chief
Financial Officers, Vice Presidents of Finance, Controllers, Chargemaster Coordinators, Database
Managers, Software Vendor Product Managers, Coding Managers, Reimbursement Specialists,
Director of Patient Accounts/Business Office, Outpatient Billing Supervisor/Coordinator,
Outpatient Billing Specialists. The contents include: Durable Medical Equipment and Prosthetics,
Pre-operative Registration, Outpatient Service “Red Flags,” Chargemaster/Charge Entry, Claims
Preparation, Claims Payment, Tracking and Reviewing Medicare Billing Guidelines.
All CPT Codes © 2003 American Medical Association * Lolita M. Jones Consulting Services
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Bunionectomy CPT Coding
Lolita M. Jones Consulting Services
FREESTANDING
AMBUALTORY SURGERY CENTER
TRAINING PROGRAMS
ASC Clinic: Multi-Specialty Procedures - This 6.5 hour program is designed for Freestanding
ambulatory surgery center (ASC) Managers (Business, Nurse, Reimbursement), Directors,
Administrators, Coding Supervisors, Coding Specialists, and Billers. The contents include:
Current Freestanding ASC Structure, Proposed Freestanding ASC Structure, Medicare Coding
Requirements, Medicare Billing Requirements, Coding Ambulatory Surgery, How To Use CPT
When Coding Ambulatory Surgery, and CPT Coding Guidelines By Body System (Integumentary,
Musculoskeletal, Respiratory, Cardiovascular and Lymphatic, Hemic and Lymphatic, Digestive
System, Urinary, Male Genital, Laparoscopy/Hysteroscopy, Female Genital, Endocrine, Nervous,
Eye and Ocular Adnexa, Auditory).
ASC Clinic: Dermatology & Plastic Surgery - This 6.5 hour program is designed for all
technical, clinical and managerial staff responsible for facility component freestanding ASC
coding and billing. The contents include: exercises based on actual outpatient operative reports;
and CPT coding guidelines for topics such as: tissue expander, pedicle flap, pressure ulcer, skin
grafts, nail avulsion and excision, scar revision, burn treatment, lesion excisions, wound repair,
adjacent tissue transfer/rearrangement, breast surgery, free flaps with microvascular anastomosis.
ASC Clinic: Eye & Oculoplastic Surgery - This 6.5 hour program is designed for all technical,
clinical and managerial staff responsible for facility component freestanding ASC coding and
billing. The contents include: exercises based on actual outpatient operative reports; and CPT
coding guidelines for topics such as: cataracts. intraocular lens, keratoplasty, trabeculectomy,
strabismus surgery, punctum plugs, tarsorrhaphy, trichiasis correction, retinal detachment repair,
vitrectomy.
All CPT Codes © 2003 American Medical Association * Lolita M. Jones Consulting Services
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Bunionectomy CPT Coding
ASC Clinic: Gastroenterology Procedures- This 6.5 hour program is designed for all technical,
clinical and managerial staff responsible for facility component freestanding ASC coding and
billing. The contents include: exercises based on actual outpatient operative reports; and CPT
coding guidelines for topics such as: hernia repair, nasogastric intubation, percutaneous
gastrostomy tube, hemorrhoidectomy, abscess/cyst drainage, dental procedures, covered and
noncovered colorectal cancer screening, gastrointestinal endoscopy, esophageal dilation.
ASC Clinic: Orthopaedic Surgery - This 1 or 2 day program is designed for all technical, clinical
and managerial staff responsible for facility component freestanding ASC coding and billing. The
contents include: exercises based on actual outpatient operative reports; and CPT coding
guidelines for topics such as: ganglion cyst, joint injections, decompression fasciotomy, treatment
of fractures/dislocations, skeletal anatomy of the hand and foot, surgical knee arthroscopy,
bunionectomy, toe-to-hand transfer with microvascular anastomosis.
ASC Clinic: Urology Procedures - This 6.5 hour program is designed for all technical, clinical
and managerial staff responsible for facility component freestanding ASC coding and billing. The
contents include: exercises based on actual outpatient operative reports; and CPT coding
guidelines for topics such as: retrograde pyelogram, ureter vs. urethra, urethral dilation, ureteral
stent, urethral stent, Burch Procedure, vesicourethropexy/urethropexy, urodynamics,
chemotherapy.
All CPT Codes © 2003 American Medical Association * Lolita M. Jones Consulting Services
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Advanced Clinic
I.
Bunionectomy CPT Coding
Clinical Coder: Skeletal Anatomy of the Foot
A quality improvement organization (QIO) reviewer recently observed that coders “don’t
understand the feet” and, as a result, encounter difficulties when they try to code procedures
performed on the foot. This coding resource reviews the bones of the foot so that coders can better
understand related procedures.
Source: Illustration by Ida Dox. From Melloni, June L., et al. Melloni’s Illustrated Review of
Human Anatomy. Philadelphia: J.B. Lippincott Co., 1988.
All CPT Codes © 2003 American Medical Association * Lolita M. Jones Consulting Services
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I.
Bunionectomy CPT Coding
Clinical Coder: Skeletal Anatomy of the Foot (continued)
Bones of the Foot are listed below:
Bone(s)
Location
Description
Phalanx; phalanges
(pl.)
Toes
The toes of one foot include a total of 14
bones, or phalanges.
Each bone consists of a base, a shaft or
body and a head. The first toe (great toe
or hallux) has a proximal and distal
phalanx. The other toes have three
phalanges each: proximal, middle and
distal.
Metatarsus; metatarsi
(pl.)
Foot
These five long bones are located
between the proximal phalanges and the
distal row of tarsal bones in the back of
the foot.
Sesamoid(s)
First metatarsal
These two small, ovoid bones are found
on the head of the first metatarsal bone.
They are found embedded within a
tendon or joint capsule, principally in the
hands and feet.
Tarsus; tarsi (pl.)
Foot
These seven bones of the posterior half of
the foot are arranged in two rows. The
distal row consists of the medial
cuneiform, intermediate cuneiform,
lateral cuneiform, cuboid and navicular;
the proximal row consists of the talus
(located at the ankle) and calcaneus (heel
bone).
All CPT Codes © 2003 American Medical Association * Lolita M. Jones Consulting Services
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I.
Bunionectomy CPT Coding
Clinical Coder: Skeletal Anatomy of the Foot (continued)
Terms for procedures frequently performed on the bones of the feet are defined as follows:
Term
Definition
Exostectomy
Removal of a benign bone tumor (exostosis)—for example, a bunion or
hallux valgus
Ostectomy
Excision of a bone
Osteoclasis
Surgical refracture of a bone in the case of a malunion of broken parts
Osteoplasty
Reconstruction or repair of a bone
Osteotomy
Surgical division or section of a bone
Sequestrectomy
Surgical removal of a piece of dead bone
Sources: Melloni, June L., et al. (Review of Human Anatomy); and Sister Agnes Clare Frenay, ssm,
Understanding Medical Terminology, Sixth Edition. St. Louis: The Catholic Health Association of
the United States, 1977.
All CPT Codes © 2003 American Medical Association * Lolita M. Jones Consulting Services
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II.
Bunionectomy CPT Coding
Bunionectomy: Background
Hallux valgus is the lateral deviation or subluxation of the great toe. With progressive subluxation
of the first metatarsophalangeal joint, footwear exerts pressure on the medial metatarsal head, and
a thickened bursa or “bunion” develops. Many different procedures can be used to correct the
bunion deformity. Common to most procedures is the excision of the exostosis (median eminence)
from the medial aspect of the first metatarsal head. Osteotomies, bone resection, and joint
replacement, which require prolonged convalescence, may be used in severe bunion cases.
The CPT codes for bunionectomies are found in the range 28110, 28290 - 28299. In their
Complete Global Service Data for Orthopaedic Surgery publication, the American Academy of
Orthopaedic Surgeons (AAOS) has identified procedures that are integral to various orthopedic
procedures. In most instances, the integral procedures listed do not warrant separate code
identification in the CPT coding system. NOTE: Use also the Medicare Hospital Outpatient
Correct Coding Initiative (CCI) edits to identify procedures that are “integral to” or “components
of” the bunionectomy codes.
Hallux valgus is the lateral deviation or subluxation of the great toe. With progressive subluxation
of the first metatarsophalangeal joint, footwear exerts pressure on the medial metatarsal head, and
a thickened bursa or “bunion” develops. Most cases are asymptomatic, but extreme cases interfere
with footwear and become painful. These are the patients who seek medical attention.
Many different procedures can be used to correct the bunion deformity. Common to most
procedures is the excision of the exostosis (median eminence) from the medial aspect of the first
metatarsal head.
Osteotomies and bone resection or joint replacement are used in severe cases and require a
prolonged convalescence.
In addition to the clinical details of these procedures, we also have included “Integral Procedures”
often performed as part of the overall procedure and, as such, do not warrant separate code
identification in CPT. Integral procedures documented are not intended to present a medical
standard of care or practice parameter for the health care community. Please note that procedure
codes are listed more than once in some instances to focus on each method/type of repair
mentioned in the code description.
Coding Tips:
• Insertion of a wire with application of skeletal traction is part of the bunionectomy procedure.
Do not code the wire insertion separately.
• All bunionectomy codes include a sesamoidectomy of the great toe.
All CPT Codes © 2003 American Medical Association * Lolita M. Jones Consulting Services
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Bunionectomy CPT Coding
Sources: William H. Rutherford, DPM., podiatric surgeon, Washington, D.C.; Lane A. Wilner,
MD, Cherry Hill, N.J.; Complete Global Service Data for Orthopaedic Surgery 2002 Edition,
American Academy of Orthopaedic Surgeons, Park Ridge, Ill.; “Coding Resource: Skeletal
Anatomy of the Foot,” St. Anthony’s HCPCS Report, September 1990, p. 3., Lolita M. Jones,
Technical Editor.
All CPT Codes © 2003 American Medical Association * Lolita M. Jones Consulting Services
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Bunionectomy CPT Coding
III. CPT Bunionectomy Codes and Case Studies
Type of Bunionectomy:
Ostectomy, partial excision, fifth metatarsal head (bunionette)
CPT Code: 28110
Procedure Description: Through a lateral longitudinal arthrotomy, the fifth metatarsophalangeal
(MP) joint is exposed. The lateral prominence or exostosis of the metatarsal head is resected, and
the capsule is tightly imbricated.
Integral Procedures: Closure of wound and repair of tissues divided for initial surgical exposure,
partial or complete; application of initial; dressing, orthosis, continuous passive motion, splint or
cast, including traction; preparation and insertion of synthetic bone substitutes (e.g.,
hydroxyapatite, coral, methylmethacrylate, demineralized bone matrix); arthrotomy; tenotomy;
synovectomy; tenolysis and/or tenosynovectomy; release joint contractures.
Diagnostic Implications: There are several types of procedures for bunionette correction. The
simple ostectomy described is indicated for prominence of the fifth metatarsal head. A chevron
osteotomy may be required for lateral deviation of the fifth metatarsal neck or a diaphyseal
osteotomy for a wide 4-5 intermetatarsal angle.
Comments (if applicable): Coding Tip - A Tailor’s bunionectomy (the same as a bunionette
excision) would be assigned to code 28110.
All CPT Codes © 2003 American Medical Association * Lolita M. Jones Consulting Services
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Bunionectomy CPT Coding
Cast Study #1:
Operative Report
Preoperative Diagnosis: Tailor’s bunion, left foot
Postoperative Diagnosis: Tailor’s bunion, left foot
Operation(s): Tailor’s bunionectomy and osteotomy, left foot
Description of Operation: The patient was brought to the Operating Room, sedated with
intravenous sedation, the left foot anesthetized with a total of 12 cc of equal amounts of .5%
Marcaine plain plus 2% Carbocaine with 1 cc of Triamcinolone added to the injectable mixture 5
cc of the mixture was used for posterior tibial nerve block. The foot was then prepped with sterile
Betadine solution, draped in a sterile fashion and ankle tourniquet applied over appropriate
padding. The tourniquet inflated to 250 mm Hg following exsanguination of the foot and ankle
with an Esmarch bandage. The Esmarch was removed and the leg placed on the table and the
procedure begun.
On the dorsolateral aspect of the left fifth metatarsophalangeal joint, a 5 cm curvilinear
incision was made. The incision was carried deep by sharp and blunt dissection, cauterizing small
bleeders with the Bovie. Subcutaneous tissue was reflected off the dorsal and medial aspect of the
fifth metatarsophalangeal joint and a dorsolinear capsulotomy was performed. The capsule was
reflected and the periosteum was tagged with simple sutures of #4-0 Vicryl for easier identification
later in the procedure upon closing. The periosteum was reflected off the dorsal, lateral and plantar
aspects of the metatarsophalangeal joint area and the lateral aspect of the metatarsal head was
resected with an oscillating saw. At this point, a failsafe drill hole was placed from dorsal to
plantar parallel with the lateral cortex of the bone approximately 1.5 cm proximal to the metatarsal
head. An oscillating saw was now used to make an osteotomy cut from the drill hole medially
through the medial cortex from dorsal to plantar. This was recut one other time and the osteotomy
easily closed with light pressure. Three drill holes were now placed, one distal and two proximal to
the osteotomy site, and a double strand of #2-0 monofilament wire was passed through these drill
holes from medial to lateral. The wire was then twisted snug with a Kocher clamp and cut, and the
cut end placed into one of the proximal drill holes. The osteotomy held in good position and kept
the bone well-aligned. There was a slight crack that developed in the lateral cortex through the
failsafe hole distally which did not displace the osteotomy at all or make it any less stable. It was,
in fact, extremely stable at the time of closure. The wound was flushed with copious amounts of
sterile saline. The periosteum and capsule were closed with simple interrupted sutures of #4-0
Vicryl. The subcutaneous tissue closed with #4-0 Vicryl and the skin with a continuous
subcutaneous stitch of #5-0 Vicryl. Mastisol’s solution and _ inch Steri-Strips were further used to
coapt the would edges. The wound was then dressed with sterile 4x4’s, Kling and a Coban
dressing applied. The tourniquet was released, normal blood flow returned to the toes as evidence
by pink coloration and blanching of the toes on pressure. Estimated blood loss was less than 1 cc.
There were no complications. The patient tolerated surgery well and left the Operating Room to go
to Recovery in apparent satisfactory condition. Specimens were disposed of.
All CPT Codes © 2003 American Medical Association * Lolita M. Jones Consulting Services
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Bunionectomy CPT Coding
Cast Study #1 cont’d
CPT Procedure/Modifier Code(s):__________________________________________
All CPT Codes © 2003 American Medical Association * Lolita M. Jones Consulting Services
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Bunionectomy CPT Coding
Case Study #2
Operative Report
Preoperative Diagnoses:
Painful hammertoe deformity right fourth digit.
Painful hammertoe deformity right fifth digit.
Painful Tailor’s bunion, right fifth metatarsal.
Postoperative Diagnoses:
Painful hammertoe deformity right fourth digit.
Painful hammertoe deformity right fifth digit
Painful Tailor’s bunion, right fifth metatarsal.
Operation
Hammertoe correct right fourth digit.
Hammertoe correct right fifth digit
Excision Tailor’s bunion, right fifth metatarsal.
Anesthesia:
IV sedation.
Local infiltration 10 cc of 1% Lidocaine plain, 0.5% Marcaine plain.
Hemostasis:
Pneumatic ankle tourniquet 250 mmHg.
Tourniquet Time: 95 minutes
Materials: 3-0 Vicryl, 4-0 Vicryl, 4-0 nylon.
Pathology: None
Procedure/Findings:
The patient was placed on the operating room table in the supine position. A well-padded ankle
tourniquet applied to her right ankle. After aforementioned anesthesia, the tourniquet was inflated
to 250 mmHg. The foot was exsanguinated and incisions were planned 4 cm in length over the
fifth metatarsal head and neck area. This was made with a #15 scalpel blade. Blunt and sharp
tissue dissection took place, denuding the fifth metatarsal of periosteal capsule. The fifth
metatarsal having noted to be significantly prominent laterally. Next, utilizing a sagittal saw, the
prominence was removed and the dorsal exostosis was rasped and smoothed. There was large
amounts of normal sterile saline and periosteum closed with a 3-0 Vicryl sutures in superficial
fascia, 3-0 Vicryl suture for the skin, 4-0 Vicryl suture running subcuticular stitch. Next the fifth
digit was examined. Two semi-elliptical incisions were made obliquely across the fifth digit and
upon sharp dissection took place to the TIPJ and DIPJ. Next, utilizing the sagittal saw, the head of
the proximal phalanx was removed. The remaining base was remodeled with a rongeur and
flushed with large amounts of normal sterile saline. The digit was then de-rotated and the tendon
All CPT Codes © 2003 American Medical Association * Lolita M. Jones Consulting Services
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Case Study #2 cont’d
repaired with a 3-0 Vicryl suture, the skin with 4-0 nylon suture holding the digit in the corrected
position.
The fourth digit was then examined and noted to be in significant abducted varus position. Two
synovial elliptical incisions were made over the PIPJ. The central ellipse of skin was removed.
Blunt and sharp digital dissection took place down to the extensive digitorum lateris tendon. This
was incised with a #15 scalpel blade. The head of the middle phalanx was then removed with a
sagittal saw and remodeled utilizing a rongeur. This was flushed with large amounts of normal
sterile saline and repaired with 3-0 Vicryl suture, derotating the toe and repaired with 4-0 nylon
suture. The areas were then injected with 3 cc of 0.5% Marcaine plain. The foot was then dressed
with Betadine soaked in Adaptic, 4 x 4’s, Kerlix and cling. The patient was transferred to the
operating room to the recovery room with vital signs stable and neurovascular status to a right foot
fully intact. She is to be partial weightbearing and surgical shoe. She was given medications for
pain. Percocet one tablet 9.6h.p.r.n. pain, Motrin 800 mg one tablet t.i.d. She is to return for a
postoperative visit in 48 hours.
CPT Procedure/Modifier Code(s):__________________________________________
All CPT Codes © 2003 American Medical Association * Lolita M. Jones Consulting Services
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Bunionectomy CPT Coding
Type of Bunionectomy:
Simple exostectomy/Silver-type procedure
CPT Code: 28290
Procedure Description: A medial longitudinal arthrotomy exposes the first MP joint. The median
eminence or exostosis is osteotomized, and the medial capsule is repaired.
Integral Procedures: Closure of wound and repair of tissues divided for initial surgical exposure,
partial or complete; application of initial; dressing, orthosis, continuous passive motion, splint or
cast, including traction; preparation and insertion of synthetic bone substitutes (e.g.,
hydroxyapatite, coral, methylmethacrylate, demineralized bone matrix); arthrotomy; synovial
biopsy; extensor tenotomy; synovectomy; capsular release and reconstruction; removal of
additional exostoses in the area of the joint; internal fixation; articular shaving; arthroscopy;
removal of bursal tissue; excision of redundant skin and closure; capsular arthroplasty; excision of
bone or synovial cysts.
Diagnostic Implications: This procedure is performed for a mild bunion deformity in which the
metatarsal head is slightly prominent on the medial side.
Comments (if applicable): A simple exostectomy involves no extensive corrective procedures but
may necessitate a release of contracted lateral structures.
All CPT Codes © 2003 American Medical Association * Lolita M. Jones Consulting Services
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Bunionectomy CPT Coding
Case Study #3
Operative Report
Preoperative Diagnosis: Hallux Valgus Deformity with Degenerative Joint Changes, Right Toe
Postoperative Diagnosis: Hallux Valgus Deformity with Degenerative Joint Changes, Right Toe
Procedure: Silver Bunionectomy, First Metatarsophalangeal Joint, Right Toe
Anesthesia: Monitored Anesthesia Care with Local Infiltration of 0.5% Marcaine Plain and 1%
Lidocaine Plain in a 1:1 Mixture Totaling 12 cc.
Hemostasis: Ankle tourniquet inflated at 250 mmHg.
Procedure: The patient was taken to the operating room and placed in the supine position on the
surgical table at which time an IV was started in the patient’s arm for purpose of intravenous
sedation and hydration. Also 1 gm of Ancef was given to the patient in an intravenous push type
form. The patient’s right lower extremity was then prepped and draped in the usual sterile manner.
Next attention was then directed to the lower right extremity which was elevated about a 45 degree
angle and was exsanguinated and a pneumatic tourniquet was inflated to 250 mmHg for the
purpose of creating hemostasis. Attention was then directed to the right metatarsophalangeal
joint where a 4.5 dorsal linear incision was made medial to the extensor hallucis longus tendon
and parallel to center over the right first metatarsophalangeal joint. The incision was deepened in
the same plane with special attention paid to all bleeders which were Bovie ligated and retracted
out of the surgical field as necessary. Special attention was paid to the neurovascular field as
necessary. Special attention was paid to the neurovascular bundle which was retracted both
medially and laterally from the surgical field. An incision was made through the subcutaneous
down to the capsule and the periosteal structure layer. With a fresh #15 blade an incision was made
through the capsule of the periosteal tissue in the same plane and was reflected medially and
laterally and dorsally to get exposure to the first metatarsal bone. Next the integrity of the first
metatarsophalangeal joint was then evaluated. The articular cartilage of the head of the first
metatarsal was observed to be nonerosive with severe areas of proliferation surrounding the dorsal
medial and dorsal lateral aspects of the first metatarsal head. With the use of the oscillating saw,
the medial eminence was resected from the site of the first metatarsal head in toto and passed
off the surgical field for pathological study. The first metatarsal head was then assessed. With the
use of a small oscillating bur all bony proliferation on the dorsal medial and dorsal lateral
aspects of the first metatarsal head were burred smooth to contour the bone, as well as the
medial aspect of the metatarsal head was burred smooth. The surgical site was then irrigated
with copious amounts of saline solution. The forefoot was then loaded and the hallux was taken
through a range of motion exhibiting good dorsiflexion. The surgical site was then flushed again
with copious amounts of saline solution. The periosteal capsule was then closed utilizing 3-0
Vicryl in a running continuous fashion. The subcutaneous tissue was then closed using 3-0 Vicryl
in a horizontal mattress suture type fashion. The skin was closed using 4-0 nylon in a continuous
running interlocking fashion. All surgical sites had been dressed with Betadine-soaked Adaptic,
sterile 4x4 gauze pads, and sterile Kling in a compressive type fashion. The tourniquet was
released and normal vascular status returned to all of the digits of the right foot. At no time during
All CPT Codes © 2003 American Medical Association * Lolita M. Jones Consulting Services
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Bunionectomy CPT Coding
Cast Study #3 cont’d
the surgical procedure was the sterile technique broken, and sterile conditions remained at all
times. After a brief period in the recovery room the patient was to be discharged with
postoperative pain medications of Vicodin one tablet to be taken p.o. q.6h. p.r.n. The patient was
dispensed one postoperative shoe and cane to be used at all times. The patient was also discharged
with written postoperative instructions. The patient is instructed if an emergency were to arise to
contact Dr. Rucker at 202-801-5474 or call the page operator at Howard University Hospital.
CPT Procedure/Modifier Code(s):__________________________________________
All CPT Codes © 2003 American Medical Association * Lolita M. Jones Consulting Services
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Bunionectomy CPT Coding
Type of Bunionectomy:
Keller
CPT Code: 28292
Procedure Description: A longitudinal medial arthrotomy with resection of the median eminence
and one-third of the base of the proximal phalanx is performed. This is followed by repair of the
plantar plate and stabilization of the repair site with a longitudinal K-wire. Repair of the medial
capsule of the MP joint is performed after excision of the redundant capsule.
Integral Procedures: Closure of wound and repair of tissues divided for initial surgical exposure,
partial or complete; application of initial; dressing, orthosis, continuous passive motion, splint or
cast, including traction; preparation and insertion of synthetic bone substitutes (e.g.,
hydroxyapatite, coral, methylmethacrylate, demineralized bone matrix); 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; capsular arthroplasty; first metatarsal head
resection; excision of bone or synovial cysts.
Diagnostic Implications: An excisional arthroplasty, joint procedure, is usually indicated for the
patient with painful hallux valgus and arthritic changes in the first MP joint.
Comments (if applicable): This procedure is recommended for elderly and sedentary individuals
with degenerative joint changes but not recommended for the young and active individual with a
joint that can be realigned structurally.
All CPT Codes © 2003 American Medical Association * Lolita M. Jones Consulting Services
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Bunionectomy CPT Coding
Type of Bunionectomy:
McBride
CPT Code: 28292
Procedure Description: The adductor tendon and transverse metatarsal ligament are released
through an incision between the first and second toe. Following this release of the contractured
lateral structures, the subluxated first MP joint is reduced, the median eminence is excised and the
medial capsule of the first MP joint imbricated through a medial arthrotomy incision.
Integral Procedures: Closure of wound and repair of tissues divided for initial surgical exposure,
partial or complete; application of initial; dressing, orthosis, continuous passive motion, splint or
cast, including traction; preparation and insertion of synthetic bone substitutes (e.g.,
hydroxyapatite, coral, methylmethacrylate, demineralized bone matrix); 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; capsular arthroplasty; first metatarsal head
resection; excision of bone or synovial cysts.
Diagnostic Implications: This method is used to correct bunion deformities that are supple and
congruent without arthritic changes.
Comments (if applicable): The postoperative care usually involves up to six weeks of weekly
dressing changes.
All CPT Codes © 2003 American Medical Association * Lolita M. Jones Consulting Services
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Bunionectomy CPT Coding
Type of Bunionectomy:
Mayo
CPT Code: 28292
Procedure Description: The incision is made over the first MP joint, the first metatarsal head and
its articular cartilage are removed, and the remaining bone is restructured. Excision of a medial
exostosis is performed with the adaptation of external joint capsule to be used as cartilage between
the metatarsal bone and the base of the first proximal phalanx.
Integral Procedures: Closure of wound and repair of tissues divided for initial surgical exposure,
partial or complete; application of initial; dressing, orthosis, continuous passive motion, splint or
cast, including traction; preparation and insertion of synthetic bone substitutes (e.g.,
hydroxyapatite, coral, methylmethacrylate, demineralized bone matrix); 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; capsular arthroplasty; first metatarsal head
resection; excision of bone or synovial cysts.
Diagnostic Implications: This procedure is not commonly used and is usually reserved for cases
of severe arthritic deformity. It reduces the foot’s ability to bear weight.
Comments (if applicable): N/A
All CPT Codes © 2003 American Medical Association * Lolita M. Jones Consulting Services
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Bunionectomy CPT Coding
Type of Bunionectomy:
Resection of joint with implant
CPT Code: 28293
Procedure Description: This procedure involves the resection of the base of the first proximal
phalanx and metatarsal head with subsequent implantation of a joint prosthesis between these
bones to produce a functional joint.
Integral Procedures: Closure of wound and repair of tissues divided for initial surgical exposure,
partial or complete; application of initial; dressing, orthosis, continuous passive motion, splint or
cast, including traction; preparation and insertion of synthetic bone substitutes (e.g.,
hydroxyapatite, coral, methylmethacrylate, demineralized bone matrix); arthrotomy; synovial
biopsy; tendon release or transfer; synovectomy; capsular release and reconstruction; removal of
additional exostoses in the area of the joint; internal fixation; arthroscopy; removal of bursal tissue;
repair of released tendon; excision of bone or synovial cysts; removal of first metatarsophalangeal
joint; all types of implants and implant fixation.
Diagnostic Implications: This is usually performed for an elderly patient with arthritic joints.
Comments (if applicable): There are five basic parameters to consider before inserting a Swanson
implant: adequate neurovascular status, adequate skin coverage, functional musculotendinous
system, adequate bone stock, patient acceptance of proposed procedure.
All CPT Codes © 2003 American Medical Association * Lolita M. Jones Consulting Services
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Bunionectomy CPT Coding
Type of Bunionectomy:
Swanson
CPT Code: 28293
Procedure Description: A dorsomedial incision is performed approximately 1.5 centimeters
medial to the extensor hallucis longus tendon, from midpoint of the proximal phalanx to midpoint
of the first metatarsal. Meticulous dissection is performed into the capsule of the first MP joint.
The base of the proximal phalanx is removed, and the articular surface of the head of the first
metatarsal is resected. A canal is reamed into the base of the proximal phalanx and the head of the
first metatarsal. One or more implants are inserted, and a meticulous closure is performed.
Integral Procedures: Closure of wound and repair of tissues divided for initial surgical exposure,
partial or complete; application of initial; dressing, orthosis, continuous passive motion, splint or
cast, including traction; preparation and insertion of synthetic bone substitutes (e.g.,
hydroxyapatite, coral, methylmethacrylate, demineralized bone matrix); any combination of hallux
valgus procedures; includes all osteotomies of the first metatarsal and the first proximal phalanx.
Diagnostic Implications: This procedure is performed for hallux valgus with subluxation and
painful/limited range of motion, hallux rigidus, revision surgery, rheumatoid arthritis, painful
degenerative joint disease, gouty arthritis, and osteochondral and intraarticular fractures.
Comments (if applicable): This procedure is to be performed after extensive training and with
knowledge of implant design and function, as well as of host function.
All CPT Codes © 2003 American Medical Association * Lolita M. Jones Consulting Services
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Bunionectomy CPT Coding
Case Study #4
Operative Report
Preoperative Diagnoses:
1. Bunion of the right foot.
2. Hallux valgus.
Postoperative Diagnoses:
1.
Bunion of the right foot.
2.
Hallux valgus.
Procedure Performed: Implant arthroplasty with correction of bunion to the right foot.
Anesthesia: Local with IV sedation.
Hemostasis: Pneumatic ankle tourniquet at 250 mmHg for 69 minutes.
Procedure: The 72-year-old patient was brought from the holding area and placed on the
operating table in the supine position. After the administration of IV sedation, a local block was
achieved using a 0.5% MARCAINE plain, approximately 17 cc used in a Mayo block fashion
about the right first metatarsal. The foot was prepped and draped and then an Esmarch bandage
was applied for exsanguination, and a pneumatic tourniquets was inflated 250 mmHg.
Bunionectomy via implant arthroplasty of the right first metatarsal phalangeal joint.
Attention was directed to the dorsal medial aspect of the right foot in the area of the first
metatarsal phalangeal joint. Just medial to the extensor tendon a 5 cm curvilinear incision was
made. The incision was deepened via sharp and blunt dissection, taking care to preserve and
protect all neurovacular structures. Those structures encountered were retracted to the side or
bovied as required. The incision was carried down to the level of the joint capsule, about the first
metatarsal phalangeal joint. Here a T-shaped capsulotomy was performed extending from the
base of the distal phalanx onto the neck of the first metatarsal and also down along the medial
aspect of the joint. All soft tissue was then dissected free from the head of the first metatarsal and
the base of the proximal phalanx. There was quite a bit of erosions noted to the joint cartilage, a lot
of gouty tophi present imbedded into the joint cartilage and pocketed into the joint capsule, The
capsule was quite thick around the head of the first metatarsal. As much as possible this was
cleaned up and removed.
I then used a power oscillating saw to resect the cartilaginous head of the first metatarsal and
the cartilaginous surface of the base of the proximal phalanx. I used a Shannon-type burr to
ream out both the first metatarsal distal portion and proximal portion of the proximal phalanx of
the great toe. In doing this I was able to create a channel for acceptance of the implant stems. I
went ahead and irrigated the wound and used sizers to measure the appropriate implant. I decided
on a total flexible hinged implant, size #3, and we used the grommets. I went ahead and placed
All CPT Codes © 2003 American Medical Association * Lolita M. Jones Consulting Services
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Bunionectomy CPT Coding
Case Study #4 cont’d
this in the normal manner and reevaluated the joint. We found that the implant was the right size
for the patient. There was good range of motion at the first metatarsal phalangeal joint with no
impingement of bone. We did a final irrigation of the wound and then began to close the soft
tissues using 3-0 and 2-0 Vicryl for the periosteal tissues and joint capsule. I performed a
capsulorrhaphy along the medial aspect of the head of the first metatarsal and then closed
subcutaneous tissues and skin using 4-0 Vicryl in a running subdermal suture fashion. I augmented
the closure with Steri-Strips, and then injected 1 cc of dexamethasone phosphate for his
postoperative anti-inflammatory effect. We dressed the wound with Adaptic, sterile 4x4 gauze, 3inch Kling, and a mildly compressive Coban wrap. Pneumatic tourniquet was released to reveal an
instantaneous reflex hyperemia to digits 1-5 of the right foot. Estimated blood loss for this
procedure was less than 5 cc. There were no specimens for pathology. The patient tolerated the
surgery and anesthesia without complication and left the operating room for recovery with vital
signs stable and neurovascular status intact.
CPT Procedure/Modifier Code(s):__________________________________________
All CPT Codes © 2003 American Medical Association * Lolita M. Jones Consulting Services
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Bunionectomy CPT Coding
Case Study #5
Operative Report
Preoperative Diagnoses:
1.
Painful bunion in the left foot.
2.
Hallux valgus.
Postoperative Diagnoses:
1.
Painful bunion in the left foot.
2.
Hallux valgus.
Procedure:
Left foot Austin bunionectomy with hemi-implant to the great toe and 3.5 mm screw fixation
Anesthesia: Pneumatic ankle tourniquet at 250 mmHg.
Procedure in Detail: The 71-year-old female patient was brought from the holding area and
placed in the operating table in the supine position. After administration of IV sedation, a local
block was achieved using 0.5% MARCAINE plain. The left foot was then prepped and draped in
the usual sterile manner. The foot was elevated and an Esmarch bandage was applied and then a
pneumatic tourniquet was inflated to 250 mmHg.
The left foot Austin bunionectomy with 3.5 mm screw fixation and hemi-implant to the great toe.
Attention was directed to the dorsomedial aspect of the left foot where a 6 cm curvilinear incision
was made just medial to the extensor tendon of the great toe. The incision was deepened via a
sharp and blunt dissection taking care to preserve and protect the neurovascular structures. The
structures encountered were retracted to the side or bovied as required. The incision was carried to
the level of the deep fascia and joint capsule around the first metatarsophalangeal joint. Here a
T-type capsulotomy was performed exposing the base of the proximal phalanx and head and
neck region of the first metatarsal. All the soft tissue was dissected away from these areas.
There was quite a bit of hypertrophic bone medially which was resected using a power
oscillating saw off the head of the first metatarsal. I then distracted the hallux to reveal the first
metatarsophalangeal joint. While I found most of the cartilage intact and nondeviated, there was
quite a bit of destruction to the cartilage itself because of chronic gouty arthritis. Almost 50% of
the cartilage was covered over by a gouty tophus which could not be scrapped clean. It was at this
point that I went ahead and decided do the hemi-implant of the great toe joint placing a
titanium implant in place. I went to the first intermetatarsal space and did a complete lateral
release of the first metatarsophalangeal joint consisting of release of the fibular sesamoidal
apparatus for release of the conjoined adductor tendon and then I bordered up the forefoot and
found the hallux to be free of all lateral contracture. I then addressed the medial head of the first
metatarsal and the anatomical and the surgical neck area and made a through-and-through Vshaped osteotomy. I then distracted the head of the metatarsal and translocated it laterally
about 0.5 cm, and then re-impacted it on to the shaft of the first metatarsal. Temporary fixation
All CPT Codes © 2003 American Medical Association * Lolita M. Jones Consulting Services
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Advanced Clinic
Bunionectomy CPT Coding
was achieved using 45 K wire. Permanent fixation was achieved using a Duvall 3.5 mm
cannulated
Case Study #5 cont’d
screw 20 mm in length abutted from dorsal proximal to plantar distal across the osteotomy site.
Once this was in place, the osteotomy was stable and in good anatomical position. I removed the
temporary fixation and then removed the medial shelf of bone created by the translocation of the
first metatarsal head. All rough osseous edges were smoothed using a Cottle rasp. I went ahead and
irrigated the wound at this time and then addressed the base of the proximal phalanx. Once the
sufficient portion of the base of the proximal phalanx was exposed, I made a through-and-through
osteotomy removing the proximal 3 to 4, maybe 5 mm base of the proximal phalanx, effectively
removing the cartilaginous surface. I then went ahead and prepped for a hemi-implant. By the size
of bone, it was felt that a median hemi-implant would be the appropriate size. I prepped the bone
creating a small hole in the edge of the medullary canal and then using the instrumentation
provided created a channel into the canal that the implant could then seat in. We then opened up a
medium Biopro hemi-implant and seated into place where it sat flush against the base of the
proximal phalanx. I then irrigated the wound again. I took the hallux range of motion and found it
to be in good alignment and free of any grinding, crepitus, nor did it catch on any aspect of the
head of first metatarsal cartilage. I went ahead and irrigated the wound one more time and
inspected for any remaining debris, of which none was found. I closed the joint capsule and
periosteal tissue using 2-0 Vicryl and 3-0 Vicryl. I then closed the subcutaneous tissues and skin
with 4-0 Vicryl in a running subcuticular suture fashion. I augmented this with Steri-Strips. I
injected 1 cc of dexamethasone phosphate for its postoperative anti-inflammatory effects. Dressed
the wound with Adaptic, sterile 4x4 gauze, 3 inch Kling, and a mildly compressive Coban wrap.
The pneumatic tourniquet was released after 58 minutes to reveal good hyperemia to digits 1
through 5 of the left foot.
Estimated blood loss for this procedure was less than 10 cc. There was no specimen for pathology.
The patient tolerated the surgery and the anesthesia without complications. She left the operating
room to recovery with vital signs stable and neurovascular status intact.
CPT Procedure/Modifier Code(s):__________________________________________
All CPT Codes © 2003 American Medical Association * Lolita M. Jones Consulting Services
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Advanced Clinic
Bunionectomy CPT Coding
Type of Bunionectomy:
Joplin-type procedure (bunion correction with tendon transplants)
CPT Code: 28294
Procedure Description: This combines the usual Silver, Keller or McBride procedure with a
tendon graft of the extensor digitorum longus tendon (located on top of each toe to extend or
straighten) to the fifth toe, which spans the transverse metatarsal arch and reduces the spreading of
the first and fifth metatarsals - a problem often seen with bunions.
Integral Procedures: Closure of wound and repair of tissues divided for initial surgical exposure,
partial or complete; application of initial; dressing, orthosis, continuous passive motion, splint or
cast, including traction; preparation and insertion of synthetic bone substitutes (e.g.,
hydroxyapatite, coral, methylmethacrylate, demineralized bone matrix); arthrotomy; synovial
biopsy; tendon transfer; synovectomy; capsular release and/or reconstruction; removal of
additional exostoses in the area of the joint; articular shaving; removal of bursal tissue; repair of
released tendon; tenotomy, extensor tendon; tendon transfer; tendon repair.
Diagnostic Implications: N/A
Comments (if applicable): This was one of the first soft tissue procedures that attempted to
resolve the dynamics of bunion deformities, which are musculoskeletal disorders.
All CPT Codes © 2003 American Medical Association * Lolita M. Jones Consulting Services
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Advanced Clinic
Bunionectomy CPT Coding
Type of Bunionectomy:
Mitchell (bunion correction with metatarsal osteotomy)
CPT Code: 28296
Procedure Description: This procedure involves a transpositional osteotomy at the neck of the
first metatarsal, with a lateral step-down or ledge and removal of the medial exostosis on the head
of the first metatarsal. Both a distal and proximal osteotomy are performed. The distal osteotomy
is from medial to lateral but does not extend through the lateral cortex of the first metatarsal; the
proximal osteotomy is proximal to the distal osteotomy and extends through the lateral cortex.
The small section of bone between the two osteotomies on the first metatarsal is removed. The
first metatarsal head is realigned laterally with the lateral ledge extending proximally over the
lateral cortex of the first metatarsal. Internal fixation then is performed followed by application of
a cast for immobilization.
Integral Procedures: Closure of wound and repair of tissues divided for initial surgical exposure,
partial or complete; application of initial; dressing, orthosis, continuous passive motion, splint or
cast, including traction; preparation and insertion of synthetic bone substitutes (e.g.,
hydroxyapatite, coral, methylmethacrylate, demineralized bone matrix); 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; excision of
bone or synovial cysts.
Diagnostic Implications: N/A
Comments (if applicable): This is an infrequently used procedure that has been replaced by the
chevron bunionectomy.
All CPT Codes © 2003 American Medical Association * Lolita M. Jones Consulting Services
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Bunionectomy CPT Coding
Case Study #6
Operative Report
Date of Surgery:
04/22/2002
Preoperative Diagnosis:
1.
2.
Left foot bunion
Hammer toe, left second toe.
Postoperative Diagnosis:
Title of the Operation:
1.
2.
Mitchell osteotomy/bunionectomy
PIP fusion of second toe hammertoe.
Anesthesia:
General endotracheal.
IV Fluids:
1000 cc.
EBL:
30 cc.
Complications:
None
Indications for Procedure:
This 55 – year old male with a history of left foot pain and large bunion and hammertoe of the
second toe, presents after failure of conservative treatment. I agreed to go ahead after discussing
risks and benefits.
Details of the Procedure:
The patient identified in pre-op holding and taken to the Operating Room. Once adequate
anesthesia was obtained, tourniquet was placed and the left lower extremity was prepped and
draped in routine sterile fashion. Leg was exsanguinated, tourniquet was inflated. A 3-4 cm
longitudinal incision was made over the medial aspect of the left great toe directly over the
bunion. We sharply incised down to the capsular layer. Then, with a distally based flap, we
All CPT Codes © 2003 American Medical Association * Lolita M. Jones Consulting Services
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Bunionectomy CPT Coding
Case Study #6 cont’d
elevated the capsule exposing underlying MP joint and bunion. Once we had adequate exposure,
we were able to take off the bunion with the sagittal saw.
Next, attention was turned on the Mitchell osteotomy. Once adequate exposure was obtained, we
placed two drill holes. The first one was about 1cm proximal to the articular surface. The second
one, about 1 _ -2cm proximal and slightly more medial. Next, sagittal saw was used to make a
transverse cut half way across, just proximal to the first drill hole. Another parallel cut was
made just behind this one and cut all the way across. The osteotome was used to take out the
wafer of bone which produced a nice ledge/step cut of the Mitchell osteotomy. Next, the
articular surface piece was immobilized medially and the step cut was wedged into place. At this
time, a #1 Vicryl stitch was used to pass through the drill holes and tie over the top for fixation. At
this time, the toe was deviated slightly laterally and the distal based capsular flap was tensioned.
This straightened the toe nicely. Next, before repairing the capsule, we again took the sagittal saw
and shaved off the medial prominence after Mitchell osteotomy. Then, the capsule was
tensioned, was repaired with interrupted #1 Vicryl keeping the toe in a corrected position.
Next, attention was turned to the hammertoe of the second small toe. Elliptical incision was
made over the dorsal aspect of the PIP joint. This again was circumcised. Next, a capsular
incision was made exposing the underlying articular surface. Articular surface were removed
with rongeur’s, both sides. Then a K-wire was inserted distally, to come out just below the
toenail. Then it was taken retrograde fashion across the IP joint to hold it immobilized. At this
time, all wounds were thoroughly irrigated.
Next, tourniquet was deflated. Adequate hemostasis was obtained. On the medial side,
subcutaneous tissue was closed with 2-0 Vicryl. Skin, with interrupted Nylon. The incision over
the IP joint of the second toe was closed with interrupted Nylon. At this time, sterile dressing was
applied and a post op shoe was placed. At this time, the patient was awake from anesthesia, taken
to Recovery in stable condition.
Disposition:
1.
2.
3.
4.
Crutch ambulation and progress to weight bearing as tolerated.
Keep the bandage on and dry until follow-up.
Follow-up with Dr. April in 7-10 days.
Medications as directed. I have given him 40 Lortab 5.
Please note: Dr. Ali was present for the entire case.
CPT Procedure/Modifier Code(s):__________________________________________
All CPT Codes © 2003 American Medical Association * Lolita M. Jones Consulting Services
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Advanced Clinic
Bunionectomy CPT Coding
Type of Bunionectomy:
Chevron (bunion correction with metatarsal osteotomy)
CPT Code: 28296
Procedure Description: This procedure begins with a medial longitudinal arthrotomy with
resection of the median eminence. A V-shaped osteotomy is performed in the first metatarsal
head, and the metatarsal head is shifted laterally (a pin may be used to stabilize the head). Then,
the shaft of the first metatarsal is smoothed flush with the head (i.e., the portion of the shaft that is
extended is smoothed to the level of or flush with the head). This realigns the toe by shifting the
metatarsophalangeal (MP) joint laterally and removing the medial prominence.
Integral Procedures: Closure of wound and repair of tissues divided for initial surgical exposure,
partial or complete; application of initial; dressing, orthosis, continuous passive motion, splint or
cast, including traction; preparation and insertion of synthetic bone substitutes (e.g.,
hydroxyapatite, coral, methylmethacrylate, demineralized bone matrix); 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; excision of
bone or synovial cysts.
Diagnostic Implications: This method is used for hallux valgus without severe metatarsus varus
(the medial displacement’s more than 15 degrees of the first metatarsal in relation to the remainder
of the lesser metatarsals); not usually performed in a patient with arthritic joints.
Comments (if applicable): N/A
All CPT Codes © 2003 American Medical Association * Lolita M. Jones Consulting Services
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Bunionectomy CPT Coding
Case Study #7
Operative Report
Preoperative Diagnosis: Bunion left foot.
Postoperative Diagnosis: Bunion left foot.
Operation: Left chevron bunionectomy.
Anesthesia: Monitored anesthesia care.
Indications:
This 56-year-old white female has had chronic pain in the left forefoot associated with bunion
deformity unrelieved by shoe modifications, strapping or padding.
Procedure/Findings: Under IV sedation, left ankle block was instilled with 1% Xylocaine and
0.25% Marcaine. The left foot and ankle were prepped and draped in the usual fashion with a
tourniquet applied to the left ankle. The tourniquet was inflated to 250 mmHg and a longitudinal 6
cm incision was made on the medial aspect of the first metatarsophalangeal joint. The soft tissue
was bluntly dissected to the joint capsule, which was incised in a distally based V and sharply
elevated. A portion of the medial eminence was resected with microoscilating saw. The lateral
attachments of collateral ligament and plantar plate were released with a McGlamry elevator.
Following that the metatarsal neck was osteotomized in a chevron fashion and the metatarsal
head translated laterally one-third of the shaft diameter and stabilized in that position with a
single 2.0 cortical screw. Following that the remainder of the medial eminence was resected
with rongeurs and the capsule was reefed with interrupted 2-0 Vicryl sutures. The tourniquet was
released. Bleeding was controlled with electrocautery. The skin was closed with interrupted 4-0
nylon sutures. Sterile dressings were applied. The patient tolerated this procedure well and was
taken to the recovery room in satisfactory condition.
CPT Procedure/Modifier Code(s):__________________________________________
All CPT Codes © 2003 American Medical Association * Lolita M. Jones Consulting Services
36
Advanced Clinic
Bunionectomy CPT Coding
Type of Bunionectomy:
Concentric-type procedure (also called crescentic osteotomy) (bunion
correction with metatarsal osteotomy)
CPT Code: 28296
Procedure Description: This procedure is a modified McBride combined with a proximal
metatarsal osteotomy. It requires three incisions or two operations on the first ray. The first
incision is over the web space between the first and second metatarsals. The second incision is
made over the medial aspect of the first metatarsal, and the third is made on the dorsal surface over
the proximal aspect of the first metatarsal. Special oscillating crescentic saw blades are used to
perform the curved metatarsal osteotomy at the proximal shaft. As a result, the distal metatarsal is
rotated to narrow the wide intermetatarsal angle. The bone may be secured with pins or screws.
Integral Procedures: Closure of wound and repair of tissues divided for initial surgical exposure,
partial or complete; application of initial; dressing, orthosis, continuous passive motion, splint or
cast, including traction; preparation and insertion of synthetic bone substitutes (e.g.,
hydroxyapatite, coral, methylmethacrylate, demineralized bone matrix); 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; excision of
bone or synovial cysts.
Diagnostic Implications: This procedure may be performed for the severe hallux valgus
associated with metatarsus varus.
Comments (if applicable): The postoperative care involves bandaging the foot weekly for six
weeks and removing the internal fixation device, such as a screw.
All CPT Codes © 2003 American Medical Association * Lolita M. Jones Consulting Services
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Advanced Clinic
Bunionectomy CPT Coding
Case Study # 8
Operative Report
Preoperative Diagnosis: Bunion, left foot.
Postoperative Diagnosis: Bunion, left foot.
Operation: Left concentric bunionectomy.
Anesthesia: General.
Indications: This 15-year-old white female has had chronic pain in the let forefoot associated with
bunion deformity unrelieved by wide toebox shoes, padding or shoe modification.
Procedure/Findings: Under general anesthesia in the supine position, a tourniquet was applied to
the left thigh. The left leg was prepped and draped in the usual fashion. The tourniquet was
inflated to 250 mmHg.
A longitudinal 4 cm incision was made on the dorsum of the foot between the first and second
metatarsophalangeal head. Soft tissue was bluntly dissected down to joint capsule, which was
incised and perforated to allow mobilization of the lateral sesamoid. A medial 5 cm incision was
made over the first metatarsophalangeal joint. Soft tissue was bluntly dissected from the joint
capsule, which was incised in a distally based V and sharply elevated. A portion of the medial
eminence was resected with a micro-oscillating saw, osteotome and rongeurs. The medial side of
the plantar plate was mobilized by sharp and blunt dissection. Following that the great toe was
aligned appropriately on the end of the first metatarsal. The base of the metatarsal was exposed
through a dorsal 5 cm incision. Soft tissue was bluntly dissected down to the periosteum, which
was incised and reflected, and a curved concentric osteotomy was fashioned through the base of
the first metatarsal. The metatarsal was realigned parallel to the second metatarsal and
stabilized in this position with a single 3.5 cortical screw lagged across the osteotomy. Following
that the medial capsule was reefed with interrupted 2-0 Vicryl sutures.
The tourniquet was released. Bleeding was controlled with electrocautery, and the wounds were
closed with interrupted 4-0 nylon sutures. Sterile dressings were applied. The patient tolerated this
procedure well and was taken to the recovery room in satisfactory condition.
CPT Procedure/Modifier Code(s):__________________________________________
All CPT Codes © 2003 American Medical Association * Lolita M. Jones Consulting Services
38
Advanced Clinic
Bunionectomy CPT Coding
Type of Bunionectomy:
Tricorrectional bunionectomy
CPT Code: 28296
Procedure Description: The bunion deformity is corrected in all three planes with a distal
metatarsal osteotomy involving a transverse V-osteotomy with a long plantar hinge using
cannulated bone screws for fixation. This procedure does not interfere with the epiphyseal growth
center of the first metatarsal.
Integral Procedures: Closure of wound and repair of tissues divided for initial surgical exposure,
partial or complete; application of initial; dressing, orthosis, continuous passive motion, splint or
cast, including traction; preparation and insertion of synthetic bone substitutes (e.g.,
hydroxyapatite, coral, methylmethacrylate, demineralized bone matrix); 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; excision of
bone or synovial cysts.
Diagnostic Implications: Juvenile hallux valgus deformity
Comments (if applicable): Coding Tip - Assign code 28296 for a Reverdin-Green osteotomy,
which is an osteotomy of the metatarsal head for bunionectomy. Also assign code 28296 for La
Greshino bunionectomy.
All CPT Codes © 2003 American Medical Association * Lolita M. Jones Consulting Services
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Advanced Clinic
Bunionectomy CPT Coding
Type of Bunionectomy:
Austin osteotomy & Reverse Austin
CPT Code: 28296 (CPT Assistant newsletter, January 1997, page 10).
Procedure Description: The first MP joint is approached through the dorsomedial incision. The
medial exostosis is excised. A V-shaped osteotomy is performed at the neck of the first metatarsal
with the apex distal. The head of the metatarsal is moved laterally to reduce the intermetatarsal
angulation. Fixation is performed in most cases, followed by closure with splinting for
immobilization.
Integral Procedures: Closure of wound and repair of tissues divided for initial surgical exposure,
partial or complete; application of initial; dressing, orthosis, continuous passive motion, splint or
cast, including traction; preparation and insertion of synthetic bone substitutes (e.g.,
hydroxyapatite, coral, methylmethacrylate, demineralized bone matrix); 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; excision of
bone or synovial cysts.
Diagnostic Implications: An Austin osteotomy is performed for mild to moderate hallux
abductor valgus for patients with no degenerative joint disease, pain-free range of motion and
dorsiflexion of the first metatarsal.
Comments (if applicable): This procedure can be used to lengthen or shorten the first metatarsal
segment.
All CPT Codes © 2003 American Medical Association * Lolita M. Jones Consulting Services
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Advanced Clinic
Bunionectomy CPT Coding
Case Study # 9
Operative Report
Date of Procedure:
January 2, 2002
Procedures Performed:
1.
2.
Bunionectomy, right foot, with osteotomy.
Excision of cyst from right first metatarsal bone.
Anesthesia:
Intravenous with local sedation 10 cc of 1% lidocaine with 0.5% Marcaine plain in 50:50 mixture.
Preoperative Diagnosis:
1.
2.
Right bunion deformity.
Bone cyst; right first metatarsal
Description of Procedure:
The 77 year-old patient was identified by the attending physician. The patient was brought to the
operating room and placed on the operating table in a normal supine position. A pneumatic ankle
tourniquet was applied to the patient’s right ankle. The patient’s right foot was prepped and
draped in a normal sterile manner. The patient’s right lower extremity was elevated and
exsanguinated using an Esmarch bandage. The extremity was then lowered to the operating room
table.
Attention was directed to the dorsal aspect of the patient’s right medial first metarsophalangeal
joint where a 5.0 cm incision was made utilizing a number 15 blade. The incision was made
deepened in the same surgical plane, being careful to retract the neurovascular structures both
medially and laterally. All bleeders were cauterized as encountered utilizing a Bovie.
A dorsal capsulotomy was performed utilizing a number 15 blade. All capsular and periosteal
tissues were removed from the head and mid shaft of the first metatarsal. This allowed for
exposure of a large proximal phalanx base, which appeared to be hypertrophied and
arthritic in nature. All arthritic bone was resected from the surgical site and removed in toto.
There was also a large medial eminence and this was resected utilizing a sagittal saw and
removed in toto from the surgical site.
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Bunionectomy CPT Coding
Case Study # 9 cont’d
Attention was then directed to the first metatarsal where a V-shaped osteotomy was made
through-and-through with the apex of the osteotomy distal within the mid shaft of the first
metatarsal head. This capital fragment was then translated laterally into a more rectus position.
The first metatarsal space was explored and found to have a tight adductor tendon. This adductor
tendon, along with the sesamoidal apparatus, was also released utilizing a number 15 blade.
The capital fragment was then fixated temporarily utilizing a 1.1. mm guidewire and 3.0 mm
cannulated screw was placed into the site, going from the dorsal proximal to the plantar distal, to
hold the fragment permanently in place.
The remaining bone meal was resected utilizing and sagittal saw and all bony prominences
were smoothed utilizing a hand rasp. The 1.1 mm guidewire was removed utilizing a K-wire
driver.
The bone cyst in the first metatarsal head was curetted and repacked with bone from the
medial eminence.
The wound was then copiously irrigated with warm normal sterile saline. Capsular tissues were
approximated utilizing 2-0 Vicryl in a simple interrupted fashion. The subcutaneous tissue was
approximated utilizing 3-0 Vicryl in a simple interrupted fashion. The skin was approximated
utilizing 4-0 Monocryl in a running subcuticular fashion. The wound was then dressed with gauze,
KLING and an ACE bandage. The pneumatic ankle tourniquet was lowered after a total
tourniquet time of 50 minutes.
Disposition:
The patient was escorted to the recovery room where vital signs were stable and vascular status
was at preoperative levels.
Postoperative Instructions:
The patient will follow up with me as an outpatient.
Hemostatis:
Pneumatic ankle tourniquet at 250mmHg for a total tourniquet time of 50 minutes.
CPT Procedure/Modifier Code(s):__________________________________________
All CPT Codes © 2003 American Medical Association * Lolita M. Jones Consulting Services
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Advanced Clinic
Bunionectomy CPT Coding
Type of Bunionectomy:
Lapidus-type procedure
CPT Code: 28297
Procedure Description: This procedure involves correcting the angulation of the first metatarsal
by fusing the first metatarsocuneiform joint and the tibial side of the base of the second metatarsal.
This is not a variation of the chevron procedure because there is no metatarsal osteotomy
performed at the proximal aspect of the first metatarsal shaft.
Integral Procedures: Closure of wound and repair of tissues divided for initial surgical exposure,
partial or complete; application of initial; dressing, orthosis, continuous passive motion, splint or
cast, including traction; preparation and insertion of synthetic bone substitutes (e.g.,
hydroxyapatite, coral, methylmethacrylate, demineralized bone matrix); arthrotomy; tendon
release or transfer; 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.
Diagnostic Implications: This procedure is performed for metatarsus primus varus, a condition in
which the metatarsal is angled toward the midline of the body, and the digit or phalanx is angled
away from the midline of the body.
Comments (if applicable): The complications include shortening of the first ray (the length of
the metatarsal to the distal phalanx) and possible transfer of loading force to the lesser metatarsals
with resulting metatarsalgia.
All CPT Codes © 2003 American Medical Association * Lolita M. Jones Consulting Services
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Advanced Clinic
Bunionectomy CPT Coding
Case Study #10
Operative Report
Date of Procedure:
April 26, 2002
Procedure Performed:
Lapidus bunionectomy with screw fixation.
Anesthesia:
MCA
Preoperative Diagnosis:
Severe hallux valgus with hypermobile first metatarsal cuneiform joint, right foot.
Postoperative Diagnosis:
Severe hallux valgus with hypermobile first metatarsal cuneiform joint, right foot.
Description of Procedure:
The 21 year-old patient was prepped and draped in the usual sterile fashion. Anesthesia was
achieved with the instillation of approximately 18cc of 1% plain Xylocaine. The foot was then
exsanguinated using an Esmarch bandage. The tourniquet was inflated at the ankle level to 250
mmHg.
A long linear incision was made with a number 15 blade across the first metatarsal cuneiform
joint area and extending down to the base of the proximal phalanx of the hallux. All bleeders
were identified and ligated.
A linear capsulotomy was made in the first metatarsophalangeal joint and the medial eminence of
the first metatarsal head was exposed. It was removed with a power saw and then rasped
smooth.
Attention was then directed to the first metatarsal interspace where the adductor tendon was
released from its attachments and the attachments to the fibular sesamoid were freed, as well as
the intermetatarsal ligaments.
Attention was then directed to the base of the first metatarsal where a linear capsulotomy was
again performed. The first metatarsal cuneiform joint was exposed with sharp and blunt
dissection. The first osteotomy performed was when a parallel portion was removed from the
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Advanced Clinic
Bunionectomy CPT Coding
Case Study 10 cont’d
cuneiform, from dorsal to plantar. Then the first metatarsal was held in the corrected position
and a small angular piece was removed with the power saw.
The area was inspected for any remaining pieces of bone, with a laminar spreader holding the joint
open. All areas were then copiously flushed.
Utilizing a 0.045 K-wire, the bone on the base of the first metatarsal was fenestrated to a
small to moderate degree. It was then held in correct apposition and two threaded K-wires
were inserted in a crossing fashion for stabilization.
An x-ray was then taken in order to confirm the position of the first metatarsal cuneiform joint. It
was found to be in good position, as were the cannulated K-wires.
Utilizing one 22 mm x 4.0 cannulated screw and one 36 mm x 4.0 cannulated screw, the joint
was then fixated. Alignment was then checked again and all areas were copiously flushed.
The capsule was then closed with 3-0 PDS interrupted sutures. The subcutaneous tissues were
closed with 4-0 Vicryl simple interrupted sutures. The flexor hallucis brevis was identified and
a small portion was removed. The skin was closed with a combination of 5-0 Monocryl running
subcuticular suture and steri-Strips. Then approximately 10cc of 0.25% Marcaine were instilled
for postoperative analgesia. A dry sterile dressing was applied. Upon release of the tourniquet,
patency of all toes was noted. A posterior splint was then applied in the operating room.
Disposition:
The patient transferred to the recovery room in good condition.
CPT Procedure/Modifier Code(s):__________________________________________
All CPT Codes © 2003 American Medical Association * Lolita M. Jones Consulting Services
45
Advanced Clinic
Bunionectomy CPT Coding
Case Study #11
Operative Report
Preoperative Diagnosis: Arthritis, left foot.
Postoperative Diagnosis: Arthritis, left foot.
Operation:
1.
Lapidus bunionectomy
2.
Arthrodesis, second and third tarsometatarsal joints.
3.
Osteotomy of the fourth metatarsal.
Anesthesia: Monitored.
Indications: This 77-year-old white female has had chronic pain in the left foot associated with
instability and degenerative joint disease in the tarsometatarsal joints, severe bunion deformity,
and pain under the metatarsal heads.
Procedure/Findings: Under IV sedation, a left ankle block was instilled with 1% Xylocaine,
0.25% Marcaine. The left foot and ankle were prepped and draped in the usual fashion with
tourniquet applied to the left ankle. The tourniquet was inflated to 250 mmHg.
A longitudinal 4 cm incision was made on the dorsal foot between the first and second
metatarsal heads. Soft tissue was bluntly dissected to lateral capsule of the first
metatarsophalangeal joint, which was incised longitudinally. The lateral sesamoid was mobilized.
He capsule was further perforated to allow realignment of the great toe parallel to the first
metatarsal. The medial aspect of the first metatarsophalangeal joint was exposed through a
longitudinal 5 cm incision. Soft tissue was bluntly dissected to the joint capsule, which was incised
in a distally based V and sharply elevated. A portion of the medial eminence was resected with
a rongeur, and the medial sesamoid and remainder of the plantar plate was mobilized with sharp
and blunt dissection.
The first tarsometatarsal joint was exposed through a dorsal 6 cm incision. Soft tissue was bluntly
dissected down to the joint. The joint capsule was incised. The articular surfaces of the
tarsometatarsal joint were resected with osteotomes and rongeurs and high speed bur, and a
portion of the medial first metatarsal was resected to allow realignment of the first metatarsal
parallel to the second. This was stabilized initially with a K wire, subsequently with a staple, and
the K wire removed. The second tarsometatarsal joint was exposed through a dorsal 5 cm
incision. Soft tissue was bluntly dissected down to the joint capsule which was incised. The dorsal
osteophytes were resected with osteotome and rongeurs. The articular surfaces of the joint
were resected with osteotome, rongeur, and high speed bur. The joint aligned appropriately. It
was stabilized with a single dorsal implanted staple. The third tarsometatarsal joint was treated
in similar fashion.
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Bunionectomy CPT Coding
Case Study #11 cont’d
Following that the fourth metatarsal was osteotomized through a dorsal 4-cm incision. The
periosteum was incised and elevated, and a horizontal osteotomy was fashioned to the fourth
metatarsal. This was stabilized with a 2.0 cortical screw. The osteotomies were carefully assessed
using a C-arm, and the alignment was deemed satisfactory. Fixation was satisfactory. The fifth
metatarsal was subsequently judged to be in satisfactory alignment and was therefore not
osteotomized.
At this point the medial capsule of the first metatarsophalangeal joint was reefed with interrupted
2-0 Vicryl sutures. The tourniquet was then released. Bleeding was controlled with electrocautery,
and all wounds were closed with interrupted 4-0 nylon sutures. Sterile dressings were applied. The
patient tolerated this procedure well and was taken to the recovery room in satisfactory condition.
CPT Procedure/Modifier Code(s):__________________________________________
All CPT Codes © 2003 American Medical Association * Lolita M. Jones Consulting Services
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Advanced Clinic
Bunionectomy CPT Coding
Type of Bunionectomy:
Bunion correction by phalanx osteotomy
CPT Code: 28298
Procedure Description: The toe is straightened by performing a closing wedge osteotomy
(removal of a wedge of bone and closing the space) at the proximal phalanx near the
metatarsophalangeal (MP) joint. The toe may be secured with a wire or closed with a suture in the
periosteum and bandaged in a straight position.
Integral Procedures: Closure of wound and repair of tissues divided for initial surgical exposure,
partial or complete; application of initial; dressing, orthosis, continuous passive motion, splint or
cast, including traction; preparation and insertion of synthetic bone substitutes (e.g.,
hydroxyapatite, coral, methylmethacrylate, demineralized bone matrix); 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.
Diagnostic Implications: This method is used for hallux valgus interphalangeous when the
proximal phalanx is the main component of the deformity.
Comments (if applicable): Coding Tip - An Akin bunionectomy is the same as a phalanx
osteotomy and would be assigned to code 28298.
Source: CPT Assistant newsletter, December 1996, page 7.
All CPT Codes © 2003 American Medical Association * Lolita M. Jones Consulting Services
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Advanced Clinic
Bunionectomy CPT Coding
Type of Bunionectomy:
By Double Osteotomy
CPT Code: 28299
Procedure Description: Code 28299 represents a combination of codes 28296 and 28310-28315.
As bunion surgery has evolved, it is now common practice to perform a double osteotomy. For the
correction of hallux valgus deformities with double osteotomy, two operative procedures must be
performed. The first is an osteotomy (i.e., chevron) of the distal first metatarsal with correction of
the hallux valgus, followed by an osteotomy of the proximal phalanx to correct additional angular
deformity. This code may also be used to report two osteotomies of the first metatarsal.
Example: A Chevron osteotomy is performed at the base of the first metatarsal, and an Akin
osteotomy is performed on the proximal phalanx. (Also see code 28296 for chevron, and 28298
for Akin osteotomy.)
Integral Procedures: Closure of wound and repair of tissues divided for initial surgical exposure,
partial or complete; application of initial; dressing, orthosis, continuous passive motion, splint or
cast, including traction; preparation and insertion of synthetic bone substitutes (e.g.,
hydroxyapatite, coral, methylmethacrylate, demineralized bone matrix); any combination of hallux
valgus procedures; includes all osteotomies of the first metatarsal and the first proximal phalanx.
Diagnostic Implications: This procedure is usually performed for a more pronounced hallux
valgus that cannot be corrected by a chevron osteotomy alone.
Comments (if applicable): N/A
All CPT Codes © 2003 American Medical Association * Lolita M. Jones Consulting Services
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Advanced Clinic
Bunionectomy CPT Coding
Case Study #12
Operative Report
Preoperative Diagnoses: Hallux abducto valgus deformity of the right foot and metatarsus primus
varus deformity of the right foot.
Postoperative Diagnosis: Hallux abducto valgus deformity of the fight foot and metatarsus
primus varus deformity of the right foot with the inclusion of arthritis of the first
metatarsophalangeal joint area of the right foot.
Operation: Austin bunionectomy and metatarsal osteotomy and Akin osteotomy of the right
hallux.
Anesthesia: Intravenous sedation.
Hemostasis: The patient had an ankle tourniquet for hemostasis.
Procedure/Findings: On October 19, 2001, the patient was taken from the preoperative holding
area to the operating room and placed on the operating room table in the supine position.
Following the induction of intravenous sedation and regional local anesthesia, the right foot was
prepped and draped in the usual sterile manner. The right foot was then elevated 60 deprees from
the horizontal plane for the purpose of preoperative exsanguination of the limb. During that threeminute time period of elevation, the pneumatic ankle tourniquet was applied to a well-padded site
just proximal to both malleoli. The pneumatic ankle tourniquet was then elevated to a level of 250
mmHg for the purpose of intraoperative hemostasis. The right lower extremity was then returned
to the operating room table. The remainder of sterile draping was completed, and the following
procedure was performed:
Austin Bunionectomy and Metatarsal Osteotomy: Attention was directed to the first
metatarsophalangeal joint area. At this time, there was noted to be a prominent bunion deformity
and medially deviated first metatarsal. Therefore, at this time, an approximately 3 cm dorsolinear
incision was created over the dorsal aspect of the first metatarsophalangeal joint of the right
foot. The incision was carried down to the level of the subcutaneous tissues, and all coursing
venous tributaries were identified, clamped, cut, electrocoagulated, and ligated as necessary. All
vital neuromuscular structures were identified, underscored, mobilized, and retracted in a medial
and lateral direction. Next, utilizing a combination of sharp and blunt dissection, the incision was
carried down into the first intermetatarsal space. A lateral release was performed. Attention was
then redirected back up to the dorsomedial aspect of the first metatarsal. At this time, a linear
capsulotomy was performed within the margins of the original skin incision. The capsular and
periosteal tissues were then dissected free in one confluent layer both medially and laterally. This
delivered into view the first metatarsophalangeal joint. It should be noted that there was a lot of
inflamed tissue around the first metatarsophalangeal joint area. There was also some exostoses of
bony prominences around the first metatarsal and a very prominent bump on the medial aspect of
the first metatarsal. At this time, utilizing a sagittal saw, an osteotomy was created within the
medial aspect of the first metatarsal. The osteotomy was oriented from dorsal to plantar, distal to
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Bunionectomy CPT Coding
Case Study #12 cont’d
proximal, through and through in such a fashion to remove that prominent bump of bone. The
exostoses and bony prominences around the dorsal aspect of the first metatarsal were also
osteotomized and removed from the surgical site. Attention was then directed to the medial
aspect of the first metatarsal. At this time, a V-shaped Austin bunionectomy was performed from
medial to lateral, through and through. The osteotomy was created in such a fashion to allow for
transposition of the first metatarsal head in a lateral direction. The first metatarsal head was
then transposed approximately one third the width of the metatarsal in a lateral direction and then
impacted onto the shaft. At this time, it was fixed in place utilizing an OrthoSorb taper pin
driven from dorsal distal lateral to proximal plantar medial. It was also fixed in place utilizing a
0.045 K-wire driven from dorsal proximal medial to plantar distal lateral. The pins crossed the
osteotomy site. The osteotomy was well fixated. Attention was then directed to the medial aspect
of the first metatarsal. At this time, the redundant cortical portion of bone, which was created
by the transposition of the first metatarsal head, was now osteotomized from dorsal to plantar,
distal to proximal, through and through. That osteotomized portion of bone was then rasped to a
more smooth and even contour. The wound was then flushed with copious amounts of sterile
saline solution. Attention was then directed to the hallux. At this time, the following procedure was
performed:
Akin Osteotomy of the Right Hallux: Attention was directed to the right hallux which was noted
to sit in a laterally deviated position. Therefore, at this time, the previous skin incision was
extended by 1.5 cm over the hallux area. The incision was carried down to the level of the
subcutaneous tissues. All coursing venous tributaries were identified, clamped, cut,
electrocoagulated, and ligated as necessary. All vital neurovascular structures were identified and
retracted from the incision site. Next, utilizing deeper dissection, the base of the proximal
phalanx was exposed. At this time a “V” or wedge-shaped osteotomy was performed in the
proximal aspect of the proximal phalanx. The osteotomy was performed in such a fashion to
allow for a wedge of bone to be removed with the apex lateral and the base medial. The wedge
or bone was removed from the surgical site. The osteotomy was feathered. It was closed and then
fixed in place utilizing a 0.045 K-wire driven from dorsal distal lateral to proximal plantar medial.
The K-wire crossed the osteotomy site. It engaged the cortices. The osteotomy was well fixated.
The wound was then flushed with copious amounts of sterile saline solution. Attention was
directed towards closure. The capsular tissues were recoapted and maintained utilizing #4-0
Vicryl. The subcutaneous tissues were recoapted and maintained utilizing #4-0. The skin was then
recoapted and maintained utilizing #5-0 Prolene. The incision was then further reinforced utilizing
_ inch Steri-Strips. An injection of Solu-Medrol was instilled around the surgical site. A dressing
consistent of Adaptic, 3 x 3’s, 3 x 3 splints, a Kling, a Kerlix, and an Ace wrap was applied in a
sterile, compressive and corrective fashion.
The patient, having tolerated the surgery and anesthesia well, with vital signs stable and afebrile,
was then transported to the post-anesthesia recovery room for further monitoring.
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Advanced Clinic
Bunionectomy CPT Coding
Case Study #12 cont’d
CPT Procedure/Modifier Code(s):__________________________________________
All CPT Codes © 2003 American Medical Association * Lolita M. Jones Consulting Services
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Advanced Clinic
Bunionectomy CPT Coding
Type of Bunionectomy:
First metatarsophalangeal joint arthrodesis
CPT Code: 28750
Procedure Description: An extensive arthrotomy is performed for exposure of the arthritic first
MP joint and removal of the remaining cartilage joint surface and subchondral bone. Compression
of the two cancellous surfaces is performed to fuse the metatarsal head and proximal phalanx. The
metatarsal head and proximal phalanx are stabilized with screws, threaded pins, or a plate.
Integral Procedures: Closure of wound and repair of tissues divided for initial surgical exposure,
partial or complete; application of initial; dressing, orthosis, continuous passive motion, splint or
cast, including traction; preparation and insertion of synthetic bone substitutes (e.g.,
hydroxyapatite, coral, methylmethacrylate, demineralized bone matrix); tenolysis and/or
tenosynovectomy; internal fixation; arthrotomy; joint debridement; capsular release, repair, and/or
reconstruction; synovial biopsy, synovectomy; osteotomy/ostectomy; local bone grafting; multiple
incisions; external fixation; sesamoidectomy; tenotomy; excision of bone cyst or spur; metatarsal
ostectomy; partial phalanx ostectomy.
Diagnostic Implications: N/A
Comments (if applicable): This is an inpatient procedure that usually requires two days in the
hospital. The postoperative follow-up care for this procedure is three months.
Coding Tip: A radical bunionectomy may be a Swanson, Chevron or other bunion procedure and
would be coded according to the procedure performed.
All CPT Codes © 2003 American Medical Association * Lolita M. Jones Consulting Services
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Advanced Clinic
Bunionectomy CPT Coding
Case Study #13
Operative Report
Preoperative Diagnosis:
1.
Hallux limitus of the left great toe joint.
2.
Arthralgia
3.
Plantar fasciitis of the left heel.
Postoperative Diagnoses:
1.
Hallux limitus of the left great toe joint.
2.
Arthralgia.
3.
Plantar fasciitis of the left heel.
Title of Procedure:
1.
Youngswick decompressional bunionectomy, left foot, with internal fixation.
2.
Endoscopic plantar fasciotomy (EPF) procedure of the left heel.
Anesthesia: Local with IV sedation.
Hemostasis: Pneumatic ankle tourniquet at 250 mmHg for 61 minutes.
Procedure in Detail: The 45-year-old female patient was brought from the holding area and
placed on the operating table in the supine position. After administration of IV sedation, a local
block was achieved using 0.5% Marcaine with epinephrine about the heel, approximately 10 cc,
and about 20 cc of 0.5% Marcaine plain in a Mayo block fashion about the left first metatarsal.
The foot was then prepped and draped in the usual sterile manner. The foot was elevated from the
table and Esmarch bandage applied. The pneumatic tourniquet was inflated to 250 mmHg.
Procedure No. 1: EPF procedure, left heel. It was decided that excessive manipulation and force
would be needed to stress across the foot while doing this procedure and it was felt we should do
this procedure first before any osteotomies in the first metatarsal. We, therefore, identified the
plantar medial aspect of the left heel at the origin of the plantar fascia and here made a 1 cm
linear incision. I used curved hemostats to bluntly open the area up to identify the most medial
extent of the plantar fascia. I then used a fascial elevator and passed it from medial-to-lateral
inferior to the plantar fascia. I then introduced the trocar cannula along the same plane and where it
dimpled the skin on the lateral aspect of the heel I made a second 1 cm linear incision and then
passed the trocar cannula through that incision. The trocar was removed leaving the cannula in
place. I introduced the camera through the medial portal and hook blade through the lateral portal.
I was able to hook the most medial extent of the plantar fascia and then sever it from a medialto-lateral direction severing effectively the medial and intermediate bands of fascia. The
plantar musculature superior to the fascia became visible once there was good separation of the
fascia. I irrigated the area and then reinspected it and found it to be free of all fibrous attachments
where I had released it. I loaded up the foot and palpated the medial arch and found it to be also
free of any tension from the plantar fascia. I removed the cannula system and then closed the
wound edges with 4-0 nylon in horizontal mattress suture fashion, one on each side of the heel.
All CPT Codes © 2003 American Medical Association * Lolita M. Jones Consulting Services
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Advanced Clinic
Bunionectomy CPT Coding
Case Study #13 cont’d
Procedure No. 2: Youngswick decompressional bunionectomy of the left foot with Duval screw
fixation 3.5 mm in diameter. Attention was directed to the dorsal medial aspect of the foot at the
area of the first metatarsophalangeal joint where there was easily palpated bony spurs present on
the head of the first metatarsal dorsally. Also noted was limited range of motion in the area of
dorsiflexion. Here, in this area, I made a 6 cm curvilinear incision. The incision was deepened via
sharp and blunt dissection taking care to preserve and protect all neurovascular structures. Those
structures encountered were retracted to the side or bovied as required. The incision was carried
down to the level of the deep fascia and joint capsule around the first metatarsophalangeal joint.
Here an inverse L-capsulotomy was performed and all soft tissues were dissected free from the
dorsal head and medial aspects of the head of the first metatarsal. This in fact did reveal quite a bit
of hypertrophic bone formation on the dorsal aspect of the head of the first metatarsal. Using
an oscillating saw, I was able to resect this bone and remove it from the wound in total. I then
inspected the joint. I found that there was cartilage satisfactorily covering the base of the
proximal phalanx, but the dorsal third of the head of the first metatarsal showed erosion of the
cartilage and rough bone. I went ahead and smoothed any rough osseous edges and then I took a
45 K-wire and drilled into the bone where the cartilage was missing to create a little bit of
bleeding, and the production, hopefully, fibrocartilage in these areas where cartilage has been
worn done. I then made a through-and-through V-shaped osteotomy from medial-to-lateral in the
head of the first metatarsal. I made a second dorsal cut about 4 to 5 cm proximal to the first
dorsal cut, effectively removing a block of bone. I then reduced the osteotomy site which allowed
for slight plantar flexion of the head of the first metatarsal and some shortening by the length of
the block of bone removed. There was good bone-to-bone fit once this was complete. I
temporarily fixated with a 45 K-wire. I then permanently fixated it with a 3.5 mm cannulated
screw. Temporary fixation was removed. The osteotomy site was found to be very stable with
good correction of the length of the first metatarsal and also some plantar flexor changes to the
head. I used a power rasp to smooth any rough osseous edges. I then irrigated the wound with
normal sterile saline, closed the wound with 3.0 Vicryl and 2.0 Vicryl closing effectively the joint
capsule and periosteal tissues around the first metatarsal. Subcutaneous tissues were closed using
3-0 Vicryl and the skin was closed in a running subcuticular suture fashion using 3-0 Vicryl and
then augmented with Steri-Strips. I injected a cc of dexamethasone phosphate divided evenly
about the heel and the first metatarsophalangeal joint. I then dressed all wounds with Adaptic,
sterile 4x4 gauze, 3 inch Kling, and a mildly compressive Coban wrap. The pneumatic tourniquet
was released after 61 minutes to reveal an instantaneous reflex hyperemia to digits 1 through 5 of
the left foot. Estimated blood loss for this procedure was less than 10 cc. There were no specimens
for Pathology. The patient tolerated the surgery and anesthesia without complication. She left the
operating room for recovery with vital signs stable and neurovascular status intact.
CPT Procedure/Modifier Code(s):__________________________________________
All CPT Codes © 2003 American Medical Association * Lolita M. Jones Consulting Services
55
Advanced Clinic
Bunionectomy CPT Coding
ANSWER KEY:
The answers below are based on the 2004 edition of the CPT code book.
Case Study 1
CPT Code: 28110-LT
Case Study 2
CPT Codes: 28285-T8, 28285-T9, 28110-RT
Case Study 3
CPT Code: 28290-RT
Case Study 4
CPT Code: 28293-RT
Case Study 5
CPT Code: 28293-LT
All CPT Codes © 2003 American Medical Association * Lolita M. Jones Consulting Services
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Advanced Clinic
Bunionectomy CPT Coding
Case Study 6
CPT Code(s)/Modifier(s):
28296-LT
28285-T1
Correction, hallux valgus (bunion), with or without sesamoidectomy; with
metatarsal osteotomy (e.g., Mitchell, Chevron, or concentric type procedure(s) –
Left Side
Correction, hammertoe (e.g., interphalangeal fusion, partial or total phalangectomy)
– Left foot, Second digit
Case Study 7
CPT Code: 28296-LT
Case Study 8
CPT Code: 28296-LT
All CPT Codes © 2003 American Medical Association * Lolita M. Jones Consulting Services
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Advanced Clinic
Bunionectomy CPT Coding
Case Study 9
CPT Code(s)/Modifier(s):
28296-RT
Correction, hallux valgus (bunion), with or without sesamoidectomy – with
metatarsal osteotomy (e.g., Mitchell, Chevron, or concentric type procedures)-Right
Side
Case Study 10
CPT Code(s)/Modifier(s):
28297-RT
Correction, hallux valgus (bunion), with or without sesamoidectomy; Lapidus type
procedure – Right Side
All CPT Codes © 2003 American Medical Association * Lolita M. Jones Consulting Services
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Advanced Clinic
Bunionectomy CPT Coding
Case Study 11
CPT Code: 28297-LT, 28308-LT
Case Study 12
CPT Codes: 28299-RT
Case Study 13
CPT Codes: 29893-LT, 28296-LT
All CPT Codes © 2003 American Medical Association * Lolita M. Jones Consulting Services
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