Case Study: Examines Code Assignments For Musculoskeletal System Procedures


Vol. 12 •Issue 24 • Page 8
Coding Corner

Case Study: Examines Code Assignments For Musculoskeletal System Procedures

Preoperative Diagnosis: Hallux valgus, left foot

Postoperative Diagnosis: Hallux valgus, left foot

Procedure Performed: Austin bunionectomy, left foot

Anesthesia: Ankle block plus local

Operative Technique: Local anesthesia was achieved via ankle block to the left foot and ankle using a total of 20 cc of 1 percent plain Xylocaine. Following sterile prep, application of Betadine solution and sterile draping, the following surgical procedure was performed using an Esmarch bandage above the left ankle for hemostasis.

Beginning at the distal one-third of the first metatarsal and extending to the interphalangeal joint, a 6-cm linear longitudinal incision was made over the dorsal medial aspect of the first MPJ medial to the long extensor tendon. All superficial bleeders were identified and coagulated. Using blunt dissection, the subcutaneous tissues were freed along the incision down to the deep fascia. The neurovascular bundle was identified and preserved.

Dissection was continued laterally into the first intermetatarsal space where the deep, transverse, intermetatarsal ligament was identified and transected. The conjoined tendon of adductor hallucis was inspected, and its insertion into the fibular sesamoid and base of the proximal phalanx was transected.

Attention was then directed to the medial first MPJ capsule where an inverted L-shaped capsular incision was made. The capsule was dissected free from the medial and dorsal aspect of the first metatarsal head. The articular cartilage of the first metatarsophalangeal articulation was inspected and found to be free of any degenerative changes. The hypertrophied medial eminence was resected with a sagittal bone saw.

A 1.3 mm K-wire was then driven in a medial to lateral fashion through the first metatarsal head and metaphysis. This served as an axis guide for the osteotomy. A V-shaped osteotomy was placed through the first metatarsal head metaphysis in a medial to lateral fashion with the base of the osteotomy projecting through the dorsal and plantar cortices and the apex at the K-wire. The K-wire was removed and upon medial to lateral compression, the capital fragment was shifted laterally and impacted onto the shaft.

The osteotomy was then fixated using double 1.3 mm Orthozor pins driven in a plantar- to-dorsal fashion. The medial shelf of one was resected. The surgical site was flushed with copious amounts of sterile saline, inspected and found to be free of debris. Stress on the MPJ and attempts at distracting the osteotomy proved a stable fixation.

The adductor tendon was then transferred to the medial capsule flap using a 3-0 Vicryl pulley suture. Redundant medial capsule was excised. Capsular structures were repaired using simple interrupted 3-0 Vicryl. The subcutaneous tissues were closed in layers using continuous lock 4-0 Vicryl. The skin was approximated using horizontal mattress 5-0 Nylon. A mixture of 4 cc of 0/5 percent plain Marcaine and 1 cc of Decadron was then infiltrated along the surgical site.

Following application of Betadine in the incision, the incision was dressed with Owen surgical silk, 4×8 gauze fluffs and 2-inch Kling. The Esmarch bandage was released and capillary refill for all digits returned STAT. The surgical dressing was stabilized using 4×8 gauze sponges, 4-inch Kling, adhesive tape and 4-inch Coban. The patient tolerated the surgery well and left the OR in stable condition.

ICD-9-CM Assignments

Preoperative:

735.0 Acquired hallux valgus

Postoperative:

735.0 Acquired hallux valgus

CPT Code Assignments

The surgeon states the bunion was repaired by an osteotomy of the metatarsal head. The alignment was then insured by the placement of the K-wire.

Refer to the term Bunion Repair in the index where you will find codes 28296Ð28299 listed. After you read through the code descriptions, you will see that the correct code is 28296. Assign modifier TA (left foot, great toe) to the facility code to identify which toe was repaired.

Facility:

28296-TA – Correction, hallux valgus (bunion), with or without sesamoidectomy; with metatarsal osteotomy

Professional:

28296 Correction, hallux valgus (bunion), with or without sesamoidectomy; with metatarsal osteotomy

Kathleen A. Mundy is a senior health care consultant with Medical Learning Inc. (MedLearn®), St. Paul, MN.

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