Certificate of Attendance
Advanced Clinic: Podiatry CPT Coding
March 11, 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 Podiatry Surgery
Advanced Clinic: Podiatry Surgery CPT Coding
Author: 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]
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TABLE OF CONTENTS
Disclaimer 3
About Lolita M. Jones Consulting Services 4
I. Introduction 9
II. Clinical Coder: Skeletal Anatomy of the Foot 10
III. Toe Modifiers 15
IV. CPT Coding Tips 16
V. Case Studies 17
VI. Sample CPT Audit Findings 50
VII. Case Studies Answer Key 52
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Disclaimer
Advanced Clinic: Podiatry Surgery 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.
PODIATRY
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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.
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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: site- of-service billing, reason for visits, discontinued surgery, medical visits, “limited follow- up services,” colorectal cancer screening, observation stay without recovery, critical care, interventional radiology, modifiers, unlisted procedure codes, units of service, UB- 92 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).
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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.
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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.
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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.
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I. Introduction
Podiatry is the specialty that manages diseases and problems of the feet. Many coding specialists find it difficult to assign Physician’s Current Procedural Terminology (CPT) codes to podiatry cases. Because so many of the podiatry procedures are currently performed in the outpatient setting, it is common for coding specialists to be “faced” with podiatry cases on a daily basis.
In order to strengthen their podiatry CPT coding skills, coding specialists need to first understand the anatomy of the foot:
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II. 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.
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Bones of the Foot are listed below:
NOTE: • The first toe (great toe or hallux) has a: proximal phalanx and a distal phalanx.
• The 2nd, 3rd, 4th, and 5th toes each have three phalanges: proximal phalanx, middle phalanx and distal phalanx.
Bone(s) Location Description
Phalanx; phalanges Toes The toes of one foot include a total of 14 (pl.) 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 Foot These five long bones are located between (pl.) the proximal phalanges and the distal row of tarsal bones in the back of the foot.
These two small, ovoid bones are found Sesamoid(s) First metatarsal on the head of the first metatarsal bone. They are found embedded within a tendon or joint capsule, principally in the hands and feet.
These seven bones of the posterior half of Foot Tarsus; tarsi (pl.) 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).
Terms for procedures frequently performed on the bones of the feet are defined as follows:
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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.
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Following are examples of CPT codes that reference specific bones of the feet:
28108 Excision of curettage of bone cyst or benign tumor, phalanges of foot
28310 Osteotomy, shortening, angular or rotational correction; proximal phalanx, first toe (separate procedure)
28530 Closed treatment of sesamoid fracture
28304 Osteotomy, tarsal bones other than calcaneus or talus;
28470 Closed treatment of metatarsal fracture; without manipulation, each
Anatomical Reference Points
Each phalanx, metatarsal, and tarsal bone consists of a:
• base (also called proximal end)
• a shaft or body and,
• a head (also called distal end).
Some CPT code descriptions specifically reference these anatomical reference points, such as:
28111 Ostectomy, complete excision; first metatarsal head
28126 Resection, partial or complete, phalangeal base, each toe
28153 Resection, condyle(s), distal end of phalanx, each toe
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Joints can be found in between the bones of the feet:
IP joint: the interphalangeal (IP) joint is located in the great toe, between the base of the distal phalanx and the head of the proximal phalanx.
DIP joint: the distal interphalangeal (DIP) joint is located in the 2nd through 5th toes, between the base of a distal phalanx and the head of a middle phalanx
MTP joint: the metatarsophalangeal (MTP) joint is located in the 1st through 5th toes, between the base of a proximal phalanx and the head of a metatarsal.
PIP joint: the proximal interphalangeal (PIP) joint is located in the 2nd through 5th toes, between the base of a middle phalanx and the head of a proximal phalanx.
Tarsometatarsal joint: the tarsometatarsal joint is located between the base of a metatarsal and the head of a tarsal bone.
Intertarsal joint: a joint that is located between two tarsal bones.
Many CPT codes specifically reference the joint involved for the podiatry procedures, such as:
28050 Arthrotomy with biopsy; intertarsal or tarsometatarsal joint
28289 Hallux rigidus correction with cheilectomy, debridement and capsular release of the first metatarsophalangeal joint
28755 Arthrodesis, great toe; interphalangeal joint
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III. Toe Modifiers
When coding, modifiers provide the means by which the reporting healthcare provider can indicate that a service or procedure that has been performed has been altered by some specific circumstance (e.g., a procedure performed on the left second toe). In the Healthcare Common Procedure Coding System (HCPCS) Level II codes, there are modifiers specifically for the left side (-LT) and right side (-RT) of the body. In addition, there are specific modifiers for each toe:
-TA Left foot, great toe -T1 Left foot, second digit -T2 Left foot, third digit -T3 Left foot, fourth digit -T4 Left foot, fifth digit -T5 Right foot, great toe -T6 Right foot, second digit -T7 Right foot, third digit -T8 Right foot, fourth digit -T9 Right foot, fifth digit.
When applicable, the modifier is appended to the CPT code which described the procedure performed on the toe. For example, has a repair of their left second hammertoe, this would be coded and modified as:
28285-T1 Correction, hammertoe (eg, interphalangeal fusion, partial or total phalangectomy) – Left foot second digit
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IV. CPT Coding Tips
Below are some quick tips to keep in mind when coding podiatry cases:
• Within a single operative report the surgeon may refer to the same anatomical reference point using synonyms (for example, the surgeon may use both “base” and “proximal end” within the same report, and both terms are synonymous with one another);
• Don’t use toe modifiers –TA through –T9 with metatarsal CPT codes, since the metatarsal bones are bones of the midfoot, they are not located in the toes/phalanges.
• Remember to repeat the code if it’s description states “each toe” and the procedure was performed on multiple toes.
• There is no CPT code for arthroplasty of the toe; use unlisted procedure code 28899. Do not assign codes 26535 or 26536 as they classify an arthroplasty of the interphalangeal joint of the finger. Please note that an arthroplasty may in fact be a hammertoe repair (see code 28285 if appropriate).
28285 Correction, hammertoe (eg, interphalangeal fusion, partial or total phalangectomy)
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V. Case Studies
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Case Study # 1. Please assign the CPT code(s)-modifier(s) for this case: ______.
OPERATIVE REPORT
Pre-Operative Diagnosis: Morton’s neuroma right foot fourth web space.
Post-Operative diagnosis: Morton’s neuroma right foot fourth web space.
Procedure Performed: Resection Morton’s neuroma.
Drains: None.
Estimated blood loss: None.
Specimen: Morton’s neuroma sent to Pathology.
Procedure: With the patient in the supine position after the usual prep an drape, under sedation with supplemented by local injection and tourniquet control with 300 mmHg after proper exsanguination of the foot, an incision was made directly over the fourth web space at the area of the metatarsal heads. This was then carried down through subcutaneous tissue. All bleeders were clamped and electrocauterized. The incision was carried down to the tissue between the metatarsal head and the plantar surface where the intermetatarsal ligament was seen. It was preserved and not transected. Directly beneath the ligament was found a stem of the Morton’s neuroma. It was grasped, traction was applied, and the neuroma was then brought into the field. It was resected from both the fourth toe medial side and the third toe lateral side insertions so the entire neuroma was then held by the proximal portion of nerve. Traction was placed on this nerve and a large section of the nerve was removed with the neuroma allowing the proximal portion to retract up into the midfoot area. When this was completed, the area was irrigated and aspirated and the usual closure was carried out using #3-0 nylon to the skin interrupted sutures. The patient had a pressure dressing applied and left the operating room in good condition after the application of a hard soled shoe.
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Case Study # 1 continued
Department of Pathology
SURGICAL PATHOLOGY REPORT
DOB: (Age 74) Sex: F
Pathologic Diagnosis:
MORTON’S NEUROMA THIRD & FOURTH TOE RT FOOT: Fragments of Skeletal Muscle and Synovial Tissue.
Nature of Specimen: MORTON’S NEUROMA THIRD & FOURTH TOE RT FOOT
Gross Description:
The specimen is received in formalin and consists of an elongated piece of tan tendinous tissue measuring 1.5 cm in length and 0.2 cm in width. The specimen is serially sectioned and entirely submitted. One cassette.
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Case Study # 2. Please assign the CPT code(s)-modifier(s) for this case: ______.
OPERATIVE REPORT
PREOP DIAGNOSIS: Large bony spur, lateral aspect, left foot.
POSTOP DIAGNOSIS: Large bony spur off cuboid bone, left foot.
PROCEDURE: Removal of bony spur from left lateral foot, cuboid bone.
The patient was given a general anesthetic agent, he was in supine position on the table and prep and drape of the left ankle and foot was done and a tourniquet was inflated. A slightly curved incision was made over the prominence of the bony hump. This was right underneath the short extensor muscle mass of the foot. It seemed to be more over the cuboid bone area. There was a large bony spur here that was quite large. All soft tissues were stripped off dorsally and volar ward. Then an osteotome and a ronguer were used to smooth out all the bony areas in the base of this spur. After this was done irrigation was carried out. 2-0 Vicryl was used to close the muscle belly and fascia and then the skin was closed with 3-0 nylon. Sterile bandage with a little compression was applied. Circulation returned promptly with tourniquet removal. The patient returned to the recovery room in good condition. One gram of Monocid antibiotic was given IV during the procedure.
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Case Study # 3. Please assign the CPT code(s)-modifier(s) for this case: ______.
OPERATIVE REPORT PREOPERATIVE DIAGNOSIS: 1. Hallux limitus, left first MPJ. 2. Degenerative joint disease, first MPJ. POSTOPERATIVE DIAGNOSIS: Same. OPERATION PERFORMED: 1. Cheilectomy, left first MPJ. 2. Subchondral drilling. ANESTHESIA: 1% Xylocaine plain and 0.25% Marcaine plan in ray block fashion. COMPLICATIONS: None. SPECIMEN: Bone and soft tissue.
PROCEDURE: The patient was seen. The chart was reviewed. The patient was brought back to the OR and placed in the classical Recumbant position. After achieving adequate IV sedation, the local mixture was infiltrated as stated. Pneumatic ankle cuff was placed on the left side, but not inflated at this time. The patient was prepped and draped in the usual sterile fashion. The left foot was exsanguinated with an Esmarch and the tourniquet was inflated to 250 mm of mercury. Attention was directed to the left first MPJ, where a 4 cm curvilinear incision was made. The extensor tendon was identified and retracted laterally. The capsule was identified. Linear capsulotomy was placed. The head and base of the left first MPJ were freed from capsular attachments. Upon doing so, there was a prominence laterally, dorsally and medially. There was a focal area of degenerative change in the midportion of the metatarsal head cartilaginous area, along with a corresponding area of bony overgrowth of the base of the proximal phalanx dorsally. Sagittal saw was used to remove all bony prominence. Ronguer was used to remove bony prominence at the base of the proximal phalanx. Areas were flushed with copious amounts of normal saline. A 0.45 K-wire was used to subchondrally drill the area of cartilaginous deficit on the first metatarsal head. Four holes were placed in and surrounding the area. Noted, was that there was bone marrow protruding, indicated adequate depth of drilling. The area was flushed with copious amounts of normal saline. The capsule was approximated using 3-0 Vicryl. The subcutaneous was reapproximated with 3-0 Vicryl. The skin was approximated with 4-0 Nylon. Steri-Strip applied. Xeroform was mildly compressive dressing was applied. The patient tolerated the procedure well without any complications. Vascular status returned to normal levels. The patient returned to the recovery room in stable and apparent satisfactory condition. The patient was given postoperative instruction and prescription for pain meds.
Case Study # 4. Please assign the CPT code(s)-modifier(s)
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OPERATIVE REPORT PREOPERATIVE DIAGNOSIS 1. Hallux rigidus with degenerative joint disease, first metatarsophalangeal joint, right foot. 2. Exostosis with bursitis, fifth metatarsophalangeal joint, right foot.
POSTOPERATIVE DIAGNOSIS 1. Hallux rigidus with degenerative joint disease, first metarsophalangeal joint, right foot. 2. Exostosis with bursitis, fifth metatarsophalangeal joint, right foot.
OPERATION 1. Cheilectomy with first metatarsophalangeal joint titanium hemi-implant, right foot. 2. Exostectomy and bursectomy, fifth metatarsophangeal joint, right foot, with drainage of gouty tophus.
ANESTHESIA Intravenous sedation with local consisting of a total of 22 cc of 0.5% plain Marcaine.
HEMOSTASIS Pneumatic ankle tourniquet, right ankle, inflated to 250 mmHg for a total of 66 minutes.
COMPLICATIONS None.
ESTIMATED BLOOD LOSS Less than 5 cc.
MATERIAL Size 3 titanium hemi-implant.
INJECTABLES 1. Intravenous Ancef, 1 gm, preoperatively. 2. Local infiltration of 1 cc Decadron (4 mg), postoperatively.
SPECIMENS None.
Case Study # 4 continued
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PROCEDURE: 72 year old male was identified in the preoperative holding area and was taken to the operating room. He was placed on the operating room table in the supine position. After obtaining intravenous sedation, the right foot was locally infiltrated with a total of 20 cc of 0.5% plain Marcaine. The right foot was then prepped and draped in the usual sterile fashion. After elevation and exsanguination of the right lower extremity, the tourniquet was elevated to 250 mmHg.
Attention was then directed to the dorsal aspect of the right foot over the first metatarsophalangeal joint. A linear incision was made, approximately 6 cm in length, and carried down through the skin and subcutaneous tissue with sharp and blunt dissection. The vital neurovascular structures were avoided during the dissection and hemostasis was maintained with electrocautery. The extensor tendon was identified and laterally retracted. A linear incision was then made in the joint capsule and periosteum, exposing the first metarsophalangeal joint and distal metatarsal shaft.
At that time, there was noted to be significant erosions and degenerative changes of the first metatarsophalangeal joint, including the metatarsal head. A sagittal saw was used to remove the degenerative bone and hypertrophic bone from the dorsal, lateral and medial aspects of the bone. A rongeur and hand rasp were used to provide a smooth contour and normal anatomic shape. The sagittal saw was again used to resect the base of the proximal phalanx for placement of the implant.
A size 3 implant was determined to be needed and the size 3 broach was then used to core out the medullary canal at the base of the proximal phalanx. The sizer was placed and this was noted to be adequate. This was then removed followed by a total irrigation of the wound and placement of the size 3 titanium hemi-implant. There was noted to be a good, smooth range of motion at that time. The head of the first metatarsal was then fenestrated with a 0.45 Kirschner wire.
The capsule was debrided and redundant capsule was excised. This was then repaired using 4-0 Vicryl suture in a running fashion. The subcutaneous tissues were then closed and reapproximated using 4-0 Vicryl sutures in a simple interrupted fashion. The skin was then reapproximated using 4-0 nylon in a running horizontal mattress fashion.
Attention was then directed to the dorsal lateral aspect of the fifth metatarsophalangeal joint. There, a linear incision was made approximately 4 cm in length. Sharp and blunt dissection was carried out, again avoiding all vital neurovascular structures and maintaining hemostasis with electrocautery. The capsule was incised. At that time, significant inflammatory fluid and gouty tophus were expressed from the joint. The capsule and periosteum were incised throughout the length of the incision, exposing the fifth metatarsal head. An exostosis was noted and resected with the rongeur. A hand rasp was used to provide a smooth contour to the fifth metatarsal head.
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Case Study # 4 continued
The joint capsule was also debrided and the bursa was excised. All gouty tophus was removed. The wound was flushed with sterile saline. The capsule was then closed using 4-0 Vicryl sutures. The subcutaneous tissues were also closed using 4-0 Vicryl sutures. The skin was closed with 4-0 nylon sutures in a running horizontal fashion.
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Case Study # 5. Please assign the CPT code(s)-modifier(s) for this case: ______.
OPERATIVE REPORT
PREOPERATIVE DIAGNOSIS: CONTRACTED FLEXOR TENDONS THIRD AND FOURTH TOES RIGHT FOOT.
POSTOPERATIVE DIAGNOSIS: CONTRACTED FLEXOR TENDONS THIRD AND FOURTH TOES RIGHT FOOT.
OPERATION: FLEXOR TENOTOMY AND CAPSULOTOMY THIRD AND FOURTH TOES RIGHT FOOT.
ANESTHESIA: LOCAL REGIONAL BLOCKADE.
PATHOLOGY: NO SPECIMENS SUBMITTED.
HEMOSTASIS: NONE.
ESTIMATED BLOOD LOSS: MINIMAL.
MATERIALS: NONE.
INJECTABLES: NONE.
COMPLICATIONS:
OPERATIVE PROCEDURE: The patient was brought into the operating room and placed on the operating table in the supine position. Local anesthesia was obtained to the third and fourth toes of the right foot using 5 cc of 0.5% Marcaine plain. The right foot was then scrubbed, prepped, and draped in the usual sterile manner.
Attention was then directed to the third toe of the right foot, where a 0.5 cm transverse incision was made at the plantar crease with a #15 blade. Dissection was carried down to the contracted flexor tendons at the proximal interphalangeal joint. The tendon was identified and incised. Attention was then directed to the distal interphalangeal joint, through the same incision to identify contracted flexor tendons and joint capsule structures. Contracted structures were incised in a transverse manner and stretched. Flexor contracture deformity was released and the digit was able to be held in a rectus position.
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Case Study # 5 continued
Attention was then directed to the fourth digit of the right foot, where a transverse incision was made along the plantar flexor crease at the proximal interphalangeal joint with a #15 blade. Dissection was then carried down to the contracted flexor tendons at the proximal interphalangeal joint, where the flexor tendon and contracted joint structures were incised transversely releasing a flexor contracture. The incision was deepened distally to release the contracted structures at the distal interphalangeal joint, allowing the fourth toe to maintain a rectus position. Steri-Strips were applied dorsally to maintain the third and fourth toes in a rectus position. Plantar structures were covered with adaptic soaked Betadine and gauze.
The patient tolerated the above procedures and anesthesia well and left the operating room with vital stable and neurovascular structure of the toes intact. Following a period of postoperative monitoring the patient was discharged home under her own recognizance. Postoperative instructions were given to the patient and the patient was instructed to make a follow-up appointment for Tuesday April 8.
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Case Study # 6_. Please assign the CPT code(s)-modifier(s) for this case: ______.
OPERATIVE REPORT
PREOPERATIVE DIAGNOSIS: Ischemic necrosis to the second toe of the left foot.
POSTOPERATIVE DIAGNOSIS: Ischemic necrosis to the second toe of the left foot.
ANESTHESIA: 1% local Xylocaine.
OPERATIVE PROCEDURE: Amputation of the second toe to the left foot.
The patient was placed in a supine position on the operating room table. Successful local anesthesia was affected with 1% Xylocaine at the base of the second toe. The toe was obviously necrotic. A curvilinear incision was made from the dorsal to plantar in the first webspace around the second toe. The second toe was disarticulated from its articulation at the metatarsophalangeal joint. The bed of the toe was then fairly irrigated; then closure was carried out. The subcutaneous dead space was closed using 2-0 Vicryl and the skin closed using 4-0 nylon. There was ample bleeding during the operation to be optimistic about the viability of the amputation site. The foot was dressed in the sterile dressing and the patient returned to the recovery room in stable condition.
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Case Study # 6 continued
SURGICAL PATHOLOGY REPORT
DOB: (Age 68) Gender: F
Specimen(s) Received A: left 2nd toe
Final Diagnosis GANGRENE LEFT SECOND TOE: Gangrene of skin and subcutaneous tissue.
*** Electronically Signed Out
Clinical History Gangrene left 2nd toe
Gross Description The specimen is labeled “left second toe.”
The specimen is received in formalin and consists of a single toe measuring 5.0 cm from the tip of the toe to the proximal margin. The toe is covered by darkly pigmented skin. The soft tissue at the margin is grossly necrotic. A necrotic area is located at the ventral aspect of the toe. Bone is submitted following decalcification. Representative sections are submitted. Multiple sections/3 cassettes Representative section submitted/hrm.
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Case Study # 7. Please assign the CPT code(s)-modifier(s) for this case: ______.
OPERATIVE REPORT
ASSISTANT None.
PREOPERATIVE DIAGNOSIS Osteomyelitis, right great toe.
POSTOPERATIVE DIAGNOSIS Osteomyelitis, right great toe.
OPERATION Amputation of the right great toe.
ANESTHESIA Monitored.
INDICATIONS: This 70-year-old white male developed chronic osteomyelitis of the right great toe which has not improved with medical care.
PROCEDURE/FINDINGS Under intravenous sedation, a right ankle block was instilled with 1% Xylocaine and 0.25% Marcaine. The right foot and ankle were prepped and draped in the usual fashion. The tourniquet was applied to the right ankle. The tourniquet was inflated to 250 mmHg. A standard fish-mouth incision was made at the level of the interphalangeal joint. The necrotic portion of the great toe was resected. The toe was disarticulated at the interphalangeal joint. The condyles of the proximal phalanx were then resected with a rongeur. Bleeding was controlled with electrocautery. The wound was closed loosely with interrupted #3-0 nylon sutures. Sterile dressings were applied. The patient tolerated the procedure well and was taken to the recovery room in satisfactory condition.
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Case Study # 8. Please assign the CPT code(s)-modifier(s) for this case: ______.
OPERATIVE REPORT
PREOPERATIVE DIAGNOSIS Hammer toe, fifth toe, right.
POSTOPERATIVE DIAGNOSIS Hammer toe, fifth toe, right.
OPERATION Arthroplasty, fifth toe, right foot.
INDICATIONS: There was noted to be a focal dermal excrescence overlying the head of the proximal phalanx and lateral aspect of the middle phalanx over the right fifth toe. Thus, the following procedure was performed.
PROCEDURE/FINDINGS: On July 23, 2002, the patient was moved from the preoperative holding room to the operating room and placed on the operating table in supine position. Following induction of a local anesthesia, the right foot was prepped and draped in the usual sterile manner. The foot was then elevated to 60 degrees above the horizontal for purpose of exsanguination. An Esmarch dressing was wrapped tightly about the foot, the cuff was inflated to 250 mmHg, and the foot was lowered to the operating table. The Esmarch dressing was removed. The following procedure was performed: Arthroplasty, fifth toe, right foot.
Attention was directed to the fifth toe where there was noted to be a focal dermal excrescence over the dorsal lateral aspect of the fifth toe. Thus a 2.5 cm dorsal linear incision was made overlying the digit. The incision was deepened through sharp and blunt dissection. With attention being paid to all bleeders, which were cut, clamped, Bovied, and ligated as necessary. All vital structures were undermined, underscored, and then were retracted medially and laterally for purpose of preservation, revealing the extensor digitorum longus tendon to the fifth toe, which was transected transversely at the level of the proximal interphalangeal joint. The tendon and capsule were elevated from their underlying osseous attachments, revealing the proximal phalangeal head. It was transected at the level of the surgical neck and extirpated from the wound in toto. All osseous prominences were rasped smooth at this time. The wound was flushed copiously with sterile saline solution. Dissection was then carried over the lateral aspect of the middle phalanx. Utilizing a double-action bone-cutting forceps, the lateral aspect of the phalanx was transected longitudinally and extirpated from the wound in toto.
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The wound was washed copiously with sterile saline solution. There was noted to be no osseous or soft tissue debris within the wound, and no rough edges remaining. Case Study # 8 continued
With the digit being held in the corrected position, the tendon was coapted and maintained, utilizing 4-0 Vicryl with simple interrupted technique. The skin was coapted and maintained utilizing 5-0 monofilament nylon with horizontal mattress technique. Then 0.25 cc of dexamethasone phosphate and 2 cc of 0.5% Marcaine were instilled through the surgical site. The foot was dressed with 4 x 4, Kling, and Coban, and then the pneumatic ankle tourniquet was released. An instantaneous capillary refill was noted.
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Case Study # 8 continued
Pathology Report
Age/Sex: 23/F Location: AMB
PREOPERATIVE DIAGNOSIS Hammertoe 5th right toe
OPERATION PERFORMED Right Arthrodesis Toe
TISSUE REMOVED A. Bone, right 5th toe
GROSS DESCRIPTION
RECEIVED LABELED BONE, RIGHT SMALL TOE, ARE TWO PIECES OF PALE WHITE TO PINK, BONY FRAGMENT MEASURING 1.0 X 0.6 X 0.5 CM AND 0.5 X 0.4 X 0.4 CM RESPECTIVELY. ALL BLOCKED FOR DECALCIFICATION.
PATH PROCEDURES
PROCEDURES: PATH DSM, DECALCIFICATION, A1 BLK, DEC
FINAL DIAGNOSIS
RIGHT 5TH TOE: FRAGMENTS OF BONE WITH MILD DEGENERATIVE CHANGE CONSISTENT WITH HAMMER TOE REPAIR.
Signed ______(signature on file) ______
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Case Study # 9. Please assign the CPT code(s)-modifier(s) for this case: ______.
OPERATIVE REPORT
PREOPERATIVE DIAGNOSIS: Hammertoe deformity, left second and third digit.
POSTOPERATIVE DIAGNOSIS: Same.
OPERATION PERFORMED: Hammertoe deformity correction, left second and third digits.
ANESTHESIA: Local IV sedation. 1% Xylocaine plain and 0.25% Marcaine plain in a digital block fashion
SPECIMENS: Bone and soft tissue.
COMPLICATIONS: None.
PROCEDURE: The patient was seen, the chart was reviewed and the patient was brought to the OR and placed in the classical Recumbant position. After achieving adequate IV sedation, local mixture was infiltrated. Attention was directed to the left foot after being prepped and draped in the usual sterile fashion. Attention was then directed to the left second and third digit, where arthroplasty was carried out. 0.045 K-wire was placed in a retrograde fashion and held the digits in place. Areas were flushed with copious amounts of normal saline. Vascular status remained normal. The skin was reapproximated using 4-0 Nylon. Mildly compressive gauze dressing was applied. The patient was given postoperative instruction. The patient tolerated the procedure well without any complications and will be followed up in our office.
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Case Study # 9 continued
SURGICAL PATHOLOGY REPORT
Sex: F
DIAGNOSIS: A. “Bone, Third Digit Left Foot”: Specimen consistent with bone removed from a left foot deformity (gross diagnosis). B. “Bone, Second Digit Left Foot”: Specimen consistent with bone removed from a left foot deformity (gross diagnosis).
Clinical Information Provided: Painful hammertoe left foot, second and third digits.
Specimens Received: Gross Description A. Received in formalin and labeled “Bone third digit left foot” is one roughly saddle- shaped fragment of gray-tan osseous tissue measuring 1.0 x 0.6 x 0.5 cm. No histologic sections are obtained; gross diagnosis only.
B. Received in formalin and labeled “Bone second digit, left foot” are two irregular fragments of gray-tan to yellow osseous tissue measuring in aggregate 1.5 x 1.4 x 0.5 cm. No histologic sections are obtained; gross diagnosis only.
Electronic Signature
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Case Study # 10. Please assign the CPT code(s)-modifier(s) for this case: ______.
OPERATIVE REPORT
PREOPERATIVE DIAGNOSIS: 1. HAMMER DIGIT SYNDROME SECOND DIGIT, THIRD DIGIT, FOURTH DIGIT, AND FIFTH DIGIT, LEFT FOOT. 2. HAMMER DIGIT SYNDROME SECOND DIGIT, THIRD DIGIT, FOURTH DIGIT, AND FIFTH DIGIT, RIGHT FOOT.
POSTOPERATIVE DIAGNOSIS: 1. HAMMER DIGIT SYNDROME SECOND DIGIT, THIRD DIGIT, FOURTH DIGIT, AND FIFTH DIGIT, LEFT FOOT. 2. HAMMER DIGIT SYNDROME SECOND DIGIT, THIRD DIGIT, FOURTH DIGIT, AND FIFTH DIGIT, RIGHT FOOT.
OPERATION: 1. ARTHROPLASTY SECOND DIGIT, THIRD DIGIT, FOURTH DIGIT, AND FIFTH DIGIT LEFT FOOT. 2. ARTHROPLASTY SECOND DIGIT, THIRD DIGIT, FOURTH DIGIT, AND FIFTH DIGIT, AND FIFTH DIGIT RIGHT FOOT.
ANESTHESIA: LOCAL WITH MONITORED ANESTHESIA CARE.
HEMOSTASIS: PNEUMATIC ANKLE TOURNIQUETS AT 250 MM/HG.
ESTIMATED BLOOD LOSS: MINIMAL.
PROCEDURE IN DETAIL: Under mild sedation the patient was brought to the operating room and placed on the operative table in the supine position. Pneumatic ankle tourniquets were then placed about both of patient’s ankles. Following IV sedation local anesthesia was obtained about both the feet utilizing 20 cc of 0.5% Marcaine plain. The feet were scrubbed, prepped, and draped in the aseptic manner. An Esmarch bandage was utilized to exsanguinate the patient’s feet, and a pneumatic ankle tourniquet was then inflated on both ankles at the same time.
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Case Study # 10 continued
Attention was then directed to the right foot. On the second, third and fourth digits of the right foot two converging 2 cm semi-elliptical transverse incisions were made over the dorsal aspect of the these digits. The incisions were centered over the distal interphalangeal and encompassed the dorsal callous present at the distal interphalangeal joint. The incisions were deepened through the subcutaneous tissue, with care being taken to identify and retract all vital neural and vascular structures. The ellipses of skin were removed in toto utilizing sharp dissection. All bleeders were cauterized and ligated as necessary.
At this time a transverse tenotomy and capsulotomy was performed to the distal interphalangeal joint of the second, third, and then fourth digits of the right foot. The head of the middle phalanx was freed of its capsular and ligamentous attachments. Next utilizing the bone saw the head of the middle phalanx was resected and passed from the operative site. The wounds were flushed with copious amounts of sterile normal saline. The extensor tendon was re-approximated and coapted utilizing 3-0 Vicryl and the skin was re-approximated and coapted utilizing 5-0 nylon.
Attention was then directed to the fifth digit of the right foot two converging 2 cm semi-elliptical transverse incisions were made over the dorsal aspect of this digit. The incisions were centered over proximal interphalangeal and encompassed the dorsal callous present at the proximal interphalangeal joint. The incisions were deepened through the subcutaneous tissue, with care being taken to identify and retract all vital neural and vascular structures. The ellipse of skin was removed in toto utilizing sharp dissection. All bleeders were cauterized and ligated as necessary.
At this time a transverse tenotomy and capsulotomy was performed to the proximal interphalangeal joint of the fifth digit of the right foot. The head of the proximal phalanx was freed of its capsular and ligamentous attachments. Next, utilizing the bone saw, the head of the proximal phalanx was resected and passed from the operative site. The wound was flushed with copious amounts of sterile normal saline. The extensor tendon was re-approximated and coapted utilizing 3-0 Vicryl and the skin was reapproximated and coapted utilizing 5-0 nylon using simple interrupted suture techniques.
Upon completion of the procedure a total of 1.5 cc of dexamethasone was infiltrated around the incision sites. The incisions were dressed with Betadine soaked adaptic and covered with sterile compressive dressings consisting of 4 by 4s and Kling. The pneumatic tourniquet was deflated and a prompt hyperemic response was noted to all digits of the right foot. An Ace wrap and postoperative shoe were then applied.
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Case Study # 10 continued
Attention was then directed to the second, third and fourth digits of the left foot. Two converging 2 cm semi-elliptical transverse incisions were made over the dorsal aspect of the these digits. The incisions were centered over the distal interphalangeal and encompassed the dorsal callous present at the distal interphalangeal joint. The incisions were deepened through the subcutaneous tissue, with care being taken to identify and retract all vital neural and vascular structures. The ellipses of skin were removed in toto utilizing sharp dissection. All bleeders were cauterized and ligated as necessary.
At this time a transverse tenotomy and capsulotomy was performed to the distal interphalangeal joint of the second, third and then fourth digits of the left foot. The head of the middle phalanx was freed of its capsular and ligamentous attachments. Next, utilizing the bone saw, the head of the middle phalanges was resected and passed from the operative site. The wounds were flushed with copious amounts of sterile normal saline. The extensor tendon was re-approximated and coapted utilizing 3-0 Vicryl and the skin was re-approximated and coapted utilizing 5-0 nylon using simple interrupted suture technique.
Attention was then directed to the fifth digit of the left foot. Two converging 2 cm semi-elliptical longitudinal incisions were made over the dorsal aspect of this digit. The incisions were centered over proximal interphalangeal joint and encompassed the dorsal callous present at the proximal interphalangeal joint. The incisions were deepened through the subcutaneous tissue, with care being taken to identify and retract all vital neural and vascular structures. The ellipse of skin was removed in toto utilizing sharp dissection. All bleeders were cauterized and ligated as necessary.
At this time, a transverse tenotomy and capsulotomy was performed to the proximal interphalangeal joint of the fifth digit of the left foot. The head of the proximal phalanx was freed of its capsular and ligamentous attachments. Next, utilizing the bone saw the head of the proximal phalanx was resected and passed from the operative site. The wound was flushed with copious amounts of sterile normal saline. The extensor tendon was re-approximated and coapted utilizing 3-0 Vicryl and the skin was reapproximated and coapted utilizing 5-0 nylon using simple interrupted suture techniques.
Upon completion of the procedure, a total of 1.5 cc of dexamethasone was infiltrated around the incision sites. The incisions were dressed with Betadine soaked adaptic and covered with sterile compressive dressing consisting of 4 by 4s and Kling. The pneumatic tourniquet was deflated and a prompt hyperemic response was noted to all digits of the left foot. An Ace wrap and postoperative shoe were then applied.
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Case Study # 10 continued
The patient tolerated the procedures and anesthesia well. The patient was transferred to the recovery room with vital signs stable and vascular status intact to all digits of both feet. Following a period of postoperative monitoring the patient was discharged home on the following written and oral postoperative instructions.
POSTOPERATIVE INSTRUCTIONS: 1. Keep the dressings clean, dry and intact. 2. To avoid excessive ambulation. 3. To ice and elevate both feet when at rest. 4. To wear a surgical shoe at all times when ambulating. 5. To contact surgeon for postoperative follow-up care or if problems may arise.
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Case Study # 11. Please assign the CPT code(s)-modifier(s) for this case: ______.
OPERATIVE REPORT
PREOPERATIVE DIAGNOSIS: 1. Bunion deformity, right foot. 2. Hammertoe deformity, right second digit.
POSTOPERATIVE DIAGNOSIS: Same.
OPERATION PERFORMED: 1. Osteobunionectomy with long V-arm with 2 screw fixation, right foot. 2. Extensor tenotomy, right second digit. 3. Flexor tenotomy, right second digit.
ANESTHESIA: Local IV sedation.
Hemostasis with pneumatic ankle cuff at 250 mm of mercury for 90 minutes.
SPECIMEN: Bone and soft tissue.
COMPLICATIONS: None.
PROCEDURE: The patient was seen. The chart was reviewed. The patient was brought back to the OR and placed in the classical Recumbant position after giving adequate IV sedation. The above mixture was infiltrated and pneumatic ankle cuff was placed on the right side at the malleolar level, but not inflated. Foot was prepped and draped in the usual sterile fashion. Attention was directed to the right first MPJ, where a 5 cm curvilinear incision was placed medial to the extensor longus tendon. Dissection was carried down to the subcutaneous tissue, being careful to avoid all neurovascular structures. Extensor brevis tendon was identified and tenotomized sharply. The first interspace dissection was carried out. Lateral capsulotomy and adductor tenotomy was carried out. Dissection was carried to the capsule medially. A linear capsulotomy was made in same plane as the incision. Next, the capsule was reflected from the first metatarsal. Sagittal saw was used to remove the dorsal osteophyte and also the dorsal medial prominence of the first metatarsal. Joint was examined to show that there was smooth cartilage present, with some are of yellowish, fibrous cartilage on the direct center of the area, but intact. Next, the V-osteotomy was made with a long dorsal arm, wings proximal and apex distal at a 60 degree angle through and through. The long V- arm encompassed approximately one half the shaft of the first metatarsal. Next, the capsule fragment was distracted and displaced medially, approximately 3 to 4 mm and packed.
Case Study # 11 continued
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Two 0.45 K-wires were placed on the dorsum to hold the osteotomy in place and two 3.0 self-tapping cannulated screws were placed with appropriate fixation noted. The K- wires were removed after the remainder of the medial prominence was resected. All areas were rasped smooth of any rough edges and the areas were flushed with copious amounts of normal saline. The medial capsulorraphy was carried out.
The capsule was reapproximated using 3-0 Vicryl. The skin was reapproximated using 4- 0 Nylon in a horizontal mattress fashion. Next, the attention was directed to the second digit, where an 11 blade was used to perform an extensor tenotomy and capsulotomy on the dorsum at the second MPJ. On doing so, unloading the foot, it was noted that the digit was held in a rectus position; however, there was mild plantar flexion noted, and because of this, a separate procedure of a plantar flexor tenotomy was carried out. Upon doing so, the digit did hold in a rectus position. 4-0 Nylon was used on the dorsal and plantar incision, one each. Steri-Strips were applied. Mild compressive dressing was applied with Ace wrap. Vascular status returned to normal after deflating tourniquet. The patient tolerated the procedure well without any completion. The patient returned to the recovery room with vital signs stable and in satisfactory condition. The patient was given postoperative instructions and pain medication. The patient is to follow-up in our office for postoperative care.
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Case Study # 11 continued
SURGICAL PATHOLOGY REPORT
Sex: F
Clinical Information Provided: Bunion deformity and hammer-toe second digit right foot.
DIAGNOSIS: “Bone Great Toe”: Specimen consistent with bone removed from a right foot (toe) deformity - gross diagnosis.
Specimens Received: Gross Description Received in formalin and labeled - “Bone right great toe” is one flat fragment of pale white osseous tissue measuring 1.5 x 0.7 x 0.2 cm. No histologic sections are obtained; gross diagnosis only.
Electronic Signature
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Case Study # 12. Please assign the CPT code(s)-modifier(s) for this case: ______.
OPERATIVE REPORT
PREOPERATIVE DIAGNOSIS: Severe recurrent hallux valgus deformity of right forefoot.
POSTOPERATIVE DIAGNOSIS: Severe recurrent hallux valgus deformity of right forefoot.
OPERATIVE PROCEDURE: Right hallux MP arthrodesis.
ANESTHESIA: General per Wood/C.R.N.A. with supplemental 0.5% plain Marcaine ankle block per surgeon for postoperative analgesia.
TOURNIQUET TIME: Slightly over one hour at 300 mmHg.
DRAINS: None.
COMPLICATIONS: None.
IMPRESSION: Percutaneous threaded K-wires.
DESCRIPTION OF PROCEDURE: After satisfactory general anesthesia was established with the patient supine on the operating room table. The tourniquet was then placed on the right thigh. Ancef 1 gm IV had been administered. After successful anesthesia was established, the right foot and ankle was prepped and draped to a sterile fashion. It was held elevated for several minutes. The tourniquet was inflated to 300 mmHg.
A dorsal incision was made along the medial border of the extensor hallicus longus tendon. Full-thickness subperiosteal flaps were developed off the base of the proximal phalanx and off the metatarsal head and neck until adequate exposure of the joint surfaces was gained. The articular surfaces were then removed with hand instruments. The subchondral base plate was left in place on the proximal phalangeal side, but perforated multiple times with a K-wire. Once adequate bone resection had been gained in order so as to allow reduction of the deformity, the threaded K-wires were placed on the base of the proximal phalanx out the end of the toe. The hallux was then positioned in proper location for fusion. The K-wires were passed into the metatarsal head. The bone was quite friable, but in spite of this, the fixation and appeared to be quite good. The wires were cut off and capped.
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Case Study # 12 continued
The wounds were irrigated and closure was obtained was obtained with interrupted 2-0 Vicryl and 4-0 nylon for the skin. A 0.5% plain ankle block was put in place prior to skin closure. The patient was awakened from anesthesia and taken to the recovery room in stable condition. No complications were encountered and counts were correct.
DISPOSITION: She will be discharged home following recovery from anesthesia with office follow-up next week. She has Tylox, #40, with no refill, for pain. She should keep the dressing dry and foot elevated. She should weight bear on heel only and report any interim problems if they occur.
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Case Study #13. Please assign the CPT code(s)-modifier(s) for this case: ______.
OPERATIVE REPORT
PREOPERATIVE DIAGNOSIS: Ganglion on the left foot and hallux valgus on the left foot.
POSTOPERATIVE DIAGNOSIS: Ganglion on the left foot and hallux valgus on the left foot.
OPERATION: Excision of the ganglion on the left foot and a simple bunionectomy on the left foot.
ANESTHESIA: Intravenous sedation.
HEMOSTASIS: The patient had an ankle tourniquet for hemostasis.
PROCEDURE/FINDINGS: On October 5, 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 left foot was prepped and draped in the usual sterile manner. The left foot was then elevated 60 degrees from the horizontal plane for the purpose of preoperative exsanguination of the limb. During that three-minute 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 left lower extremity was then returned to the operating room table. The remainder of sterile draping was completed. The following procedure was performed.
EXCISION OF GANGLION ON THE LEFT FOOT: Attention was directed to the left foot, where there was a recurrent, non-resolving ganglion around the first metatarsophalangeal joint area of the left foot. Therefore, at this time, two semi- elliptical incisions were created over the dorsomedial aspect of the first metatarsal in such a fashion to allow for removal of the ulceration in the skin which is part of the ganglionic cyst. That wedge of skin was removed completely from the surgical site. The incision was then further 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, underscored, mobilized, and retracted from the incision site. This delivered into view a very thick, well-defined soft tissue mass. The edges and periphery of the mass were identified and resected from
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Case Study # 13 continued their surrounding tissue. Then that mass was removed completely from the surgical site and sent to pathology for both gross and microscopic examination. At the conclusion of this procedure, attention was directed to the first metatarsophalangeal joint area; and the following procedure was performed:
SIMPLE BUNIONECTOMY OF THE LEFT FOOT: At this time, the previous skin incision was carried down to the level of the subcutaneous tissues, down into the area of the capsular tissues over the first metatarsophalangeal joint. 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 area. It should be noted that there was a very large hallux abducto valgus deformity with a prominent first metatarsal head. The articulating cartilage was no longer effective. Much of that had been destroyed. At this time, utilizing a sagittal saw, an osteotomy was created from dorsal to plantar, distal to proximal, through and through in such a fashion to remove that prominent bump of bone on the medial aspect of the first metatarsal. It should be noted that the bone was very soft and osteoporotic. That bone was released from all remaining soft tissue attachments and extirpated in toto from the surgical site. Attention was then directed to the osteotomized portions of bone that were rasped to a more smooth and even contour. The wound was flushed with copious amounts of sterile saline solution, and attention was directed towards closure. The capsular tissues were recoapted and maintained utilizing #4-0 Vicryl in a simple interrupted fashion. The subcutaneous tissues were then recoapted and maintained utilizing #4-0 Vicryl in a simple interrupted fashion. The skin structures were then recoapted and maintained utilizing #4-0 nylon in a simple interrupted fashion. Attention was then directed towards bandaging, where Adaptic, 3 x 3’s, 3 x 3 splints, a Kling, a Kerlix and an Ace wrap were applied in a sterile, compressive and corrective fashion. The pneumatic ankle tourniquet to the patient’s left foot was rapidly deflated, and normal instantaneous capillary fill time was noted to return to digits one through five of the patient’s left foot. The patient, having tolerated the surgery and anesthesia well, with vital signs stable and afebrile, was then transported from the operating room to the post- anesthesia recovery room for further monitoring.
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Case Study # 14. Please assign the CPT code(s)-modifier(s) for this case: ______.
OPERATIVE REPORT
PREOPERATIVE DIAGNOSIS: Rheumatoid arthritis with hallux valgus and sublux, first metatarsophalangeal joint. Rigid hammertoe deformities of all lesser digits. Chronic metatarsalgia, left foot.
POSTOPERATIVE DIAGNOSIS: Rheumatoid arthritis with abductovalgus and subluxation, first metatarsophalangeal joint. Rigid hammertoe contractures of the lesser digits.
OPERATION: Keller bunionectomy with 0.62 pin fixation, left foot. Pan-metatarsal head resection, left foot. Arthrodesis of the third, fourth and fifth digits, left foot, with 0.45 pin fixation.
ANESTHESIA: IV sedation with local infiltration consisting of a total of 20 cc of 0.5% Marcaine plain and a local ankle block.
HEMOSTASIS: Left ankle tourniquet at 250 mmHg for a total of 101 minutes.
ESTIMATED BLOOD LOSS: Less than 20 cc.
MATERIALS: A 0.062 K wire and three, 0.045 K wires.
INJECTABLES: 20 cc of 1% Xylocaine plain, intraoperatively.
COMPLICATIONS: None.
PATHOLOGY: Bone and soft tissue specimen.
PROCEDURE/FINDINGS: The patient was identified in the preoperative holding area, taken to the operating room and placed on the operating room table in the supine position. After obtaining IV sedation, the left foot was anesthetized with a local ankle block and the left foot and ankle was then prepped and draped in the usual sterile fashion. After elevation of the extremity and exsanguination, the tourniquet was elevated to 250 mmHg. Attention was then directed to the dorsal aspect of the first metatarsophalangeal joint on the left foot, where a dorsal longitudinal incision was made, approximately 6 cm in length. Chevron blunt dissection was carried avoiding vital neurovascular structures and maintaining hemostasis with electrocautery. Dissection was carried out down to the level of the first metatarsophalangeal joint capsule. The extensor
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Case Study # 14 continued tendon was identified and retracted laterally. A longitudinal incision was made to the capsule and along the periosteum exposing the first metatarsophalangeal joint. Significant degenerative changes were noted, along with subluxation of the joint. Sagittal saw was then used to resect the base of the proximal phalanx and also partial resection of the head of the first metatarsal. All bony irregularities were also removed with rongeur and remodeled with sagittal saw and hand rasp. A complete lateral release was performed of the joint capsule in order to facilitate medial reduction of the hallux. Attention was then directed to the dorsal aspect of the third metatarsophalangeal joint where a longitudinal incision was made approximately 3 cm in length, extending to the base of the proximal phalanx. Again, sharp and blunt dissection was carried out avoiding vital neurovascular structures and maintaining hemostasis with electrocautery. Dissection was carried out down to the level of the metarsophalangeal joint and the capsule was incised. A sagittal saw was used to resect the head of the third metatarsal with the cut being oriented dorsal distal to the plantar proximal. Attention was then directed to the proximal interphalangeal joint of the third toe where a transverse incision was made, approximately 1 cm in length. Dissection was carried out to the level of the extensor tendon, which was then incised, at the level of the joint, medial and lateral collateral ligaments were released, exposing the head of the proximal phalanx. This was resected with a sagittal saw, obtaining reduction of the hammertoe deformity. The cartilage on the base of the middle phalanx was then denuded with sagittal saw and curette. At that time a 0.045 K-wire was driven in a retrograde fashion, across the proximal interphalangeal joint and then driven proximally into the third metatarsal maintaining reduction of the hammertoe deformity and metatarsophalangeal joint contracture. The dorsal incision over the third toe was reapproximated with 4-0 nylon in a simple interrupted fashion. Subcutaneous closure was performed over the third metatarsophalangeal joint with a 3-0 Vicryl in a simple interrupted fashion, followed by skin reapproximation with 4-0 nylon. Attention was then directed to the dorsal aspect of the fourth and fifth toe and metatarsophalangeal joint where the same procedures were then performed reducing the hammertoe contractor and resecting the fourth and fifth metatarsal head. Fixation and closure was performed the same. At that time, attention was redirected back to first metatarsophalangeal joint, where retrograde fashion a 0.062 K-wire was placed through the hallux and then proximally into the first metatarsal maintaining reduction of the hallux valgus deformity. Capsular structures were closed using 3-0 Vicryl in a simple interrupted fashion. The skin was then reapproximated with 4-0 nylon in a running horizontal fashion. Prior to closure, all wounds were irrigated copiously with sterile saline and Bacitracin solution. No procedure was performed to the second metatarsophalangeal joint or second toe, because this has been surgically removed in a previous surgery three to four years ago. All wounds were dressed with Adaptic, 4/4 gauze and bulky compressive sterile dressing to the entire left foot and ankle. The tourniquet was released after a total of 101 minutes with instantaneous perfusion and capillary refill to the digits on the left foot.
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Case Study # 14 continued
The patient tolerated the procedure and anesthesia well. She was taken to recovery with vital signs stable and vascular status intact to the left foot. She has been given postoperative medications for pain control and instructions for no weightbearing on the left foot. She will follow-up in my office in approximately 5-7 days.
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Case Study # 14 continued
PATHOLOGY REPORT
Age/Sex: 78/F Location: AMB
PREOPERATIVE DIAGNOSIS: Rheumatoid foot
OPERATION: Left arthroplasty, arthrodesis foot, pan-metatarsal head resection foot, Arthroplasty 2-5 foot Arthrodesis
TISSUE REMOVED: A. Bone and soft tissue
GROSS DESCRIPTION: Received labeled bone and soft tissue L foot. The specimen consists of three pieces of pearl white to yellow and pink bony tissue fragment ranging in size from 1.1 - 1.8 cm in greatest dimensions. All blocked for decalcification.
PATH PROCEDURES: Path DSM, Decalcification, A1 BLK, DEC
FINAL DIAGNOSIS: Bone and soft tissue, right foot, excision: Benign bone and cartilage with severe degenerative changes present. A few cartilaginous fragments, consistent with loose bodies, are identified, but histologic features diagnostic for rheumatoid arthritis are not identified.
Signed ______(Signature on file) ______
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VI. Sample CPT Audit Findings
Below are the written summaries provided to a Hospital after the author performed a CPT coding review of a sample of their ambulatory surgery cases in 2002:
Medical Record#: 1 Discharge Date: 06/13/02
This Managed Care patient was seen for a second metatarsal osteotomy and a right fourth digit arthroplasty, both of which were coded correctly as 28308 and 28285. However, the Tailor’s bunionectomy was inappropriately coded as 28296 (Correction of bunion with metatarsal osteotomy). Please delete code 28296 and assign 28110 (Ostectomy, partial excision, fifth metatarsal head). Per the operative report for this case: “. . . the fifth metatarsophalangeal joint, where an approximate 4.5-cm linear incision was then made. . . fifth metatarsal . . . exostosis was resected in toto. . . an Austin-type osteotomy was then performed.”
A Tailor’s bunionectomy procedure involves a lateral longitudinal arthrotomy, in which the fifth metatarsophalangeal (MP) joint is exposed. The lateral prominence or exostosis of the metatarsal head is resected, and the capsule is tightly imbricated.
Medical Record#: 2 Discharge Date: 03/27/02
The Medicare patient was seen for a right hallux metatarsophalangeal (MP) arthrodesis, which was inappropriately coded as 28292 (bunion correction). Delete 28292 and assign 28750-RT (Arthrodesis great toe, metatarsophalangeal joint). Per the operative report: “. . . flaps were developed off the base of the proximal phalanx and off the metatarsal head and neck. . . bone resection had been gained in order to allow reduction of the deformity, the threaded K-wires were placed on the base of the proximal phalanx out the end of the toe. . . the K-wires were passed into the metatarsal head. . . the fixation appeared to be quite good.”
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Medical Record#: 3 Discharge Date: 11/24/02
The Commercial patient was seen for a radical bunionectomy with osteotomy, which was correctly coded as 28296. However, the first metatarsophalangeal (MTP) joint exostectomy was inappropriately coded. Please delete code 28288. Per the American Academy of Orthopaedic Surgeons (AAOS), code 28296 includes “removal of additional exostoses in the area of the joint.”
Medical Record#: 4 Discharge Date: 09/09/02
The Medicare patient was seen for bilateral radical bunionectomy with osteotomy, which was coded as a unilateral surgery with code 28296. Please append bilateral procedure modifier –50 to code 28296. Per the operative report: “Attention was then directed to the dorsal aspect of the left foot, where a procedure identical to that described for the right foot was performed. . . “
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VII. Case Studies Answer Key
Case Study 1 28080-RT
Case Study 2 28104-LT
Case Study 3 28289-LT
Case Study 4 28289-RT 28899-RT 28288-RT
Case Study 5 28272-T7 28272-T7-59 28272-T8 28272-T8-59 28234-T7 28234-T7-59 28234-T8 28234-T8-59
Case Study 6 28820-T1
Case Study 7 28825-T5
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Case Study 8 28285-T9
Case Study 9 28285-T1 28285-T2
Case Study 10 28285-T1 28285-T2 28285-T3 28285-T4 28285-T6 28285-T7 28285-T8 28285-T9
Case Study 11 28285-T6 28232-T6 28296-RT
Case Study 12 28750-RT
Case Study 13 28290-LT
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Case Study 14 28292-LT 28112-LT 28112-LT-59 28113-LT 28285-T2 28285-T3 28285-T4
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