Coding Anesthesia Provided for Bunionectomy

Coding Anesthesia Provided for Bunionectomy

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Coding Anesthesia Provided for Bunionectomy

Dawn Seelye, RHIA

Preoperative Diagnosis: Hallux abductovalgus deformity, right foot

Procedure Performed: Austin bunionectomy with fixation, right foot

Surgical Specimens: Bone identified grossly as normal; not sent for pathological identification

Type of Anesthesia: Monitored anesthesia care (MAC)

Anesthesia Provider: Certified registered nurse anesthetist (CRNA), not medically directed

Dawn Seelye Indications for Procedure: The patient is a 48-year-old female with a bunion of the right foot. She has had problems with this for some time, and it is progressively becoming more uncomfortable. As far as her symptoms go, it doesn’t matter what type of shoe she wears. She has tried a variety of widths, but none have met with much success.

On examination of the right foot, the patient has a very noticeable bunion deformity. There is no limitation or crepitation of range of motion. Radiographs taken today confirm a defined bunion deformity of the right foot. There are noticeable osteoporotic changes as well. The deformity has noticeable increase in the intermetatarsal angle with an increased hallux abductus angle as well.

Operative Procedure: The patient was brought to the operating room and placed on the operative room table in the supine position. Local anesthesia was infiltrated in an ankle-block technique with a total of 7 cc of 2% lidocaine and 1:1 mixture of 8 cc of 2% lidocaine and 0.5% marcaine.

Standard prep and Betadine application were performed followed by sterile draping with hemostasis. A tourniquet was applied just proximal to the ankle joint and inflated to 250 mm Hg, and the following procedures were performed.

A linear incision was made extending from the level of the anterior one-third of the first metatarsal level to the base of the proximal phalanx. With continued sharp dissection, wound margins were further underscored and retracted. Superficial vessels were identified and either electrocoagulated or retracted away from the wound site. The vital structures were identified and reflected away from the wound site. The capsular tissue was incised in a traditional inverted L capsulotomy. The tissue was reflected away from the wound site, and the medial eminence of the first metatarsal head was resected. The area was flushed.

An extensor brevis tenotomy was performed, the first intermetatarsal space was incised and an adductor tenotomy was performed. The area was again flushed.

Attention was then directed back to the first metatarsal head where a Chevron-type osteotomy was performed. Then, the capital fragment was laterally displaced and temporarily fixated with a K-wire. The tibial sesamoid position was excellent, and a good reduction was seen. This was permanently fixated with two 2-mm Synthes screws. K-wire was retrograded, and the redundant medial eminence of the first metatarsal head was resected. The area was flushed with copious amounts of sterile saline.

Sesamoid position continued to be excellent, and good range of motion continued. Tissues were closed in layers by means of multiple simple sutures of 4-0 PDS, 4-0 Vicryl and 4-0 nylon. Then, the tourniquet was released, and the capillary filling time returned immediately. A total of 0.5 cc of Decadron and 5 cc of 0.5% Marcaine were infiltrated into the wound site.

Dressing consisted of Betadine impregnated Adaptic gauze, 4×4 fluff sponges, 4-inch Kerlix and a 4-inch elastic wrap. The patient tolerated everything well and was released to phase-two recovery in stable condition.

Postoperative Diagnosis: Hallux abductovalgus deformity, right foot

ICD-9-CM Code Assignments

735.0 Hallux valgus

CPT Codes and Modifiers

For Medicare patients:

01480-QZ-QS Anesthesia for open procedures on bones of lower leg, ankle and foot; not otherwise specified

For Non-Medicare patients:

28296-QZ-QS Correction, hallux valgus (bunion), with or without sesamoidectomy; with metatarsal osteotomy (e.g., Mitchell, Chevron or concentric-type procedures)

Rationale: When assigning CPT codes for anesthesia services, first determine the type of anesthesia being administered and by whom. Then, assign the appropriate codes. Currently, Medicare requires assignment of an anesthesia CPT code, while most other payers require the primary or principle surgical CPT code.

Because this patient is experiencing significant pain and cannot wear shoes due to the deformity, the decision was made to perform a bunionectomy with fixation on the right foot.

Because this is not a Medicare patient, you would locate the surgical code for Bunion Repair…28296­28299 in the index of the CPT manual. Several different types of bunion repairs and their codes are listed below this entry. In the case above, the surgeon used the Mitchell-Chevron (Austin) procedure. Checking the code and description for this procedure shows that code 28296 is correct.

A CRNA provided the anesthesia service, and no anesthesiologist was present. Therefore, modifier -QZ would be assigned. To reflect that the service was performed under MAC, also assign modifier -QS.

If this was a Medicare case, take the surgical CPT code and use the American Society of Anesthesiologists’ (ASA) crosswalk. Look up the surgical CPT code to identify the appropriate anesthesia CPT code. Both the -QZ and -QS modifiers would be appended.

Dawn Seelye is a senior health care consultant with Medical Learning Inc. (MedLearn®), St. Paul, MN.

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