Certificate of Attendance - hcmarketplace.comhcmarketplace.com/media/supplemental/2561_acmaterials.pdfCertificate of Attendance Advanced Clinic: Podiatry CPT Coding March 11, 2004

Certificate of AttendanceAdvanced Clinic: Podiatry CPT Coding

March 11, 2004

_____________________________________NAME

Lolita M. Jones, RHIA, CCSPresenter

The American Health Information Management Association (AHIMA) has approved this program fortwo (2) continuing education clock hours in the External Forces content area.

Retain this certificate as evidence of participation.

Advanced Clinic PodiatrySurgery

All CPT Codes 2003 American Medical Association * Lolita M. Jones Consulting Services 1

Advanced Clinic:

Podiatry Surgery CPT Coding

Author:

Lolita M. Jones, RHIA, CCSLolita 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.

Advanced Clinic Podiatry Surgery


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



Disclaimer

Advanced Clinic: Podiatry Surgery CPT Coding is designed to provide accurate and authoritativeinformation in regard to the subject covered. Every reasonable effort has been made toensure the accuracy of the information within these pages. However, the ultimate responsibility lies withthe user.

Lolita M. Jones Consulting Services and staff make no representation, guarantee or warranty, express orimplied, that this compilation is error-free or that the use of this publication willprevent differences of opinion or disputes with Medicare or other third-party payers, andwill 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 systemowned and maintained by the American Medical Association.

Please contact Lolita M. Jones, RHIA, CCS at:(V) 301-292-8027(Fax) 301-292-8244Coding 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, servicedescription, 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 useof the original purchaser. This consent does not extend to other kinds of copying, such as for generaldistribution, for advertising or promotional purposes, for creating new collective works, or for resale.

PODIATRY



About Lolita M. Jones Consulting ServicesHOSPITAL TRAINING PROGRAMS

Coding Training: www.hcprofessor.com(V) 301-292-8027

(FAX) 301-292-8244E-mail: [email protected]

BIOGRAPHY:

Lolita M. Jones, RHIA, CCS, is an independent consultant specializing in hospitaloutpatient and ambulatory surgery center coding, billing, reimbursement, and operations.Ms. Jones recently launched her web-based coding program at www.EZMedEd.com. Shehas over 15 years of experience in publishing, training, and auditing for the hospitaloutpatient and freestanding ambulatory surgery center (ASC) markets. Ms. Jones hasearned both the Registered Health Information Administrator and Certified CodingSpecialist credentials from the American Health Information Management Association(AHIMA) in Chicago, IL. Ms. Jones resides in Fort Washington, Maryland, and she hasdeveloped 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, ReimbursementSpecialists, Compliance Auditors, Hospital-Based Clinic Managers, and ALL hospitalstaff responsible for outpatient coding including emergency room, ancillary departmentand hospital-based clinic staff. The contents include general guidelines, steps for coding,and official CPT guidelines for surgical procedures that are commonly performed in thehospital outpatient setting. Exercises based on actual ambulatory surgery operativereports will be used to strengthen the attendees’ understanding of the guidelinespresented.

APC Institute: Impact on Emergency Services: This 3 hour program is designed forEmergency Department: Directors, Managers, Supervisors, and Nurses; RegistrationStaff, 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 Screeningwithout Treatment, Critical Care, “Clotbuster” Drugs, Tissue Adhesive Wound Closure,and Documentation Guidelines.



APC Institute: Outpatient Compliance Action Plan: This 6.5 hour program isdesigned for Compliance Department Staff (Corporate Officers, Directors, Managers,Analysts, Auditors); Health Information Management Staff (Directors, CodingManagers/Supervisors, Coding Specialists); Risk Managers, APC Coordinators,Reimbursement Specialists, Decision Support Analysts, Outpatient Billing Supervisors,Outpatient Billing Specialists, Software Vendor Product Managers, ALL staff responsiblefor facility component outpatient coding in: Registration, Hospital-Based Clinics,Ancillary Departments, and the Emergency Department. The contents include: BriefOverview 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, criticalcare, 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 isdesigned for nursing, utilization management, case management, and other health careprofessionals responsible for health records documentation. The contents includeambulatory payment classification (APC)-related clinical documentation requirements andmanagement tips for the following sites of service: Emergency Room, ObservationBeds/Unit, Ambulatory Surgery, Hospital-Based Outpatient Departments/Clinics, PainManagement Clinic, Series/Recurring Services, Partial Hospitalization Program, CastRoom, Ancillary Testing Areas, and Utilization Management.

APC Institute: Coding Guidelines for Hospitals - This 1 or 2 day program is designedfor all technical, clinical and managerial staff responsible for facility component outpatientcoding that will directly impact ambulatory payment classification (APC) payments.The contents include: Ambulatory Surgery Reimbursement under APCs, APC DataReporting Requirements, Medicare Hospital Outpatient Edits, Outpatient BillingProcedures and Guidelines, Ambulatory Claims Rejection Monitors, Peer ReviewAmbulatory Surgery Review, Coding System Reviews, How to Use ICD-9-CM, How toUse 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).



Modifier Clinic: Hospital Outpatient Issues: This 6.5 hour program is designed forcoding, reimbursement, compliance, billing, database management, ancillary, and clinicstaff responsible for modifier programming, reporting, billing, and auditing. The contentsinclude: Modifier Reporting Requirements, Official Medicare Guidelines, RecommendedHospital Front-End Modifier Edits, Electronic/On-Line UB-92 Reporting of Modifiers,Coding and Billing Aborted/Discontinued Procedures, ICD-9-CM vs. Medicare CodingGuidelines, Unsuccessful vs. Aborted/Discontinued Procedures, Documentation ofReduced/Discontinued Procedures, Testing Potential Coders, Software Encoder ModifierEdits, Interventional Radiology Procedures, Information System Upgrades, Data QualityReview, Radiology Modifier Reporting Issues, Ancillary Department Modifier Reportingfor Hospitals, and Exercises/Case Studies.

APC Institute: Hospital Financial and Operational Issues: This 6.5 hour program isdesigned for hospital executives, directors, chargemaster coordinators,coding/reimbursement staff, and information system/database managers who willimplement ambulatory payment classifications (APCs). The contents include: GeneralOverview of APCs, APC Data Reporting Requirements, APC Policy Issues, Developinga Plan of Action, Conducting Hospital-Wide APC Education, and Assessing CurrentOutpatient Operations for: Overall Hospital, Management Information Systems,Business Office/Patient Accounts, Health Information Management, AncillaryDepartments/Chargemaster, Emergency Room, Hospital-Based Clinics, Hospital-OwnedSatellite Facilities, Hospital-Based Physician Coding and Billing, and UtilizationManagement.

APC Institute: Billing and Reimbursement Issues. This 6.5 hour program is designedfor Chief Financial Officers, Vice Presidents of Finance, Controllers, ChargemasterCoordinators, Database Managers, Software Vendor Product Managers, CodingManagers, Reimbursement Specialists, Director of Patient Accounts/Business Office,Outpatient Billing Supervisor/Coordinator, Outpatient Billing Specialists. The contentsinclude: Durable Medical Equipment and Prosthetics, Pre-operative Registration,Outpatient Service “Red Flags,” Chargemaster/Charge Entry, Claims Preparation, ClaimsPayment, Tracking and Reviewing Medicare Billing Guidelines.



Lolita M. Jones Consulting ServicesFREESTANDING

AMBUALTORY SURGERY CENTERTRAINING PROGRAMS

ASC Clinic: Multi-Specialty Procedures - This 6.5 hour program is designed forFreestanding ambulatory surgery center (ASC) Managers (Business, Nurse,Reimbursement), Directors, Administrators, Coding Supervisors, Coding Specialists, andBillers. The contents include: Current Freestanding ASC Structure, ProposedFreestanding ASC Structure, Medicare Coding Requirements, Medicare BillingRequirements, Coding Ambulatory Surgery, How To Use CPT When CodingAmbulatory 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 forall technical, clinical and managerial staff responsible for facility component freestandingASC coding and billing. The contents include: exercises based on actual outpatientoperative reports; and CPT coding guidelines for topics such as: tissue expander, pedicleflap, pressure ulcer, skin grafts, nail avulsion and excision, scar revision, burn treatment,lesion excisions, wound repair, adjacent tissue transfer/rearrangement, breast surgery, freeflaps with microvascular anastomosis.

ASC Clinic: Eye & Oculoplastic Surgery - This 6.5 hour program is designed for alltechnical, clinical and managerial staff responsible for facility component freestandingASC coding and billing. The contents include: exercises based on actual outpatientoperative reports; and CPT coding guidelines for topics such as: cataracts. intraocularlens, keratoplasty, trabeculectomy, strabismus surgery, punctum plugs, tarsorrhaphy,trichiasis correction, retinal detachment repair, vitrectomy.



ASC Clinic: Gastroenterology Procedures- This 6.5 hour program is designed for alltechnical, clinical and managerial staff responsible for facility component freestandingASC coding and billing. The contents include: exercises based on actual outpatientoperative reports; and CPT coding guidelines for topics such as: hernia repair, nasogastricintubation, percutaneous gastrostomy tube, hemorrhoidectomy, abscess/cyst drainage,dental procedures, covered and noncovered colorectal cancer screening, gastrointestinalendoscopy, esophageal dilation.

ASC Clinic: Orthopaedic Surgery - This 1 or 2 day program is designed for alltechnical, clinical and managerial staff responsible for facility component freestandingASC coding and billing. The contents include: exercises based on actual outpatientoperative reports; and CPT coding guidelines for topics such as: ganglion cyst, jointinjections, decompression fasciotomy, treatment of fractures/dislocations, skeletalanatomy of the hand and foot, surgical knee arthroscopy, bunionectomy, toe-to-handtransfer 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 codingand 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.



I. Introduction

Podiatry is the specialty that manages diseases and problems of the feet. Manycoding specialists find it difficult to assign Physician’s Current ProceduralTerminology (CPT) codes to podiatry cases. Because so many of the podiatryprocedures are currently performed in the outpatient setting, it is common for codingspecialists to be “faced” with podiatry cases on a daily basis.

In order to strengthen their podiatry CPT coding skills, coding specialists need to firstunderstand the anatomy of the foot:



II. Clinical Coder: Skeletal Anatomy of the FootA quality improvement organization (QIO) reviewer recently observed that coders “don’tunderstand the feet” and, as a result, encounter difficulties when they try to codeprocedures performed on the foot. This coding resource reviews the bones of the foot sothat coders can better understand related procedures.

Source: Illustration by Ida Dox. From Melloni, June L., et al. Melloni’s Illustrated Review of HumanAnatomy. Philadelphia: J.B. Lippincott Co., 1988.



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)

Phalanx; phalanges(pl.)

Metatarsus; metatarsi(pl.)

Sesamoid(s)

Tarsus; tarsi (pl.)

Location

Toes

Foot

First metatarsal

Foot

Description

The toes of one foot include a total of 14bones, or phalanges.

Each bone consists of a base, a shaft orbody and a head. The first toe (great toeor hallux) has a proximal and distalphalanx. The other toes have threephalanges each: proximal, middle anddistal.

These five long bones are located betweenthe proximal phalanges and the distal rowof tarsal bones in the back of the foot.

These two small, ovoid bones are foundon the head of the first metatarsal bone.They are found embedded within atendon or joint capsule, principally in thehands and feet.

These seven bones of the posterior half ofthe foot are arranged in two rows. Thedistal row consists of the medialcuneiform, intermediate cuneiform, lateralcuneiform, cuboid and navicular; theproximal row consists of the talus(located at the ankle) and calcaneus (heelbone).

Terms for procedures frequently performed on the bones of the feet are defined asfollows:



Term Definition

Exostectomy Removal of a benign bone tumor (exostosis)—for example, abunion or hallux valgus

Ostectomy Excision of a bone

Osteoclasis Surgical refracture of a bone in the case of a malunion of brokenparts

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 theUnited States, 1977.



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



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 ofthe 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 metatarsaland 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 capsularrelease of the first metatarsophalangeal joint

28755 Arthrodesis, great toe; interphalangeal joint



III. Toe Modifiers

When coding, modifiers provide the means by which the reporting healthcare provider canindicate that a service or procedure that has been performed has been altered by somespecific circumstance (e.g., a procedure performed on the left second toe). In theHealthcare Common Procedure Coding System (HCPCS) Level II codes, there aremodifiers 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 theprocedure performed on the toe. For example, has a repair of their left secondhammertoe, this would be coded and modified as:

28285-T1 Correction, hammertoe (eg, interphalangeal fusion, partial or totalphalangectomy) – Left foot second digit



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 sameanatomical reference point using synonyms (for example, the surgeon may useboth “base” and “proximal end” within the same report, and both terms aresynonymous with one another);

• Don’t use toe modifiers –TA through –T9 with metatarsal CPT codes, sincethe metatarsal bones are bones of the midfoot, they are not located in thetoes/phalanges.

• Remember to repeat the code if it’s description states “each toe” and theprocedure was performed on multiple toes.

• There is no CPT code for arthroplasty of the toe; use unlisted procedure code28899. Do not assign codes 26535 or 26536 as they classify an arthroplastyof the interphalangeal joint of the finger. Please note that an arthroplasty mayin fact be a hammertoe repair (see code 28285 if appropriate).

28285 Correction, hammertoe (eg, interphalangeal fusion, partial or total phalangectomy)



V. Case Studies



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, undersedation with supplemented by local injection and tourniquet control with 300 mmHgafter proper exsanguination of the foot, an incision was made directly over the fourthweb space at the area of the metatarsal heads. This was then carried down throughsubcutaneous tissue. All bleeders were clamped and electrocauterized. The incision wascarried down to the tissue between the metatarsal head and the plantar surface where theintermetatarsal ligament was seen. It was preserved and not transected. Directly beneaththe ligament was found a stem of the Morton’s neuroma. It was grasped, traction wasapplied, and the neuroma was then brought into the field. It was resected from both thefourth toe medial side and the third toe lateral side insertions so the entire neuroma wasthen held by the proximal portion of nerve. Traction was placed on this nerve and alarge section of the nerve was removed with the neuroma allowing the proximalportion to retract up into the midfoot area. When this was completed, the area wasirrigated and aspirated and the usual closure was carried out using #3-0 nylon to the skininterrupted sutures. The patient had a pressure dressing applied and left the operatingroom in good condition after the application of a hard soled shoe.



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 tantendinous tissue measuring 1.5 cm in length and 0.2 cm in width. The specimen is seriallysectioned and entirely submitted. One cassette.



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 tableand prep and drape of the left ankle and foot was done and a tourniquet was inflated. Aslightly curved incision was made over the prominence of the bony hump. This was rightunderneath the short extensor muscle mass of the foot. It seemed to be more over thecuboid bone area. There was a large bony spur here that was quite large. All softtissues were stripped off dorsally and volar ward. Then an osteotome and a ronguerwere used to smooth out all the bony areas in the base of this spur. After this wasdone irrigation was carried out. 2-0 Vicryl was used to close the muscle belly and fasciaand then the skin was closed with 3-0 nylon. Sterile bandage with a little compressionwas applied. Circulation returned promptly with tourniquet removal. The patientreturned to the recovery room in good condition. One gram of Monocid antibiotic wasgiven IV during the procedure.




OPERATIVE REPORTPREOPERATIVE 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 wasbrought back to the OR and placed in the classical Recumbant position. After achievingadequate IV sedation, the local mixture was infiltrated as stated. Pneumatic ankle cuffwas placed on the left side, but not inflated at this time. The patient was prepped anddraped in the usual sterile fashion. The left foot was exsanguinated with an Esmarch andthe tourniquet was inflated to 250 mm of mercury. Attention was directed to the leftfirst MPJ, where a 4 cm curvilinear incision was made. The extensor tendon wasidentified and retracted laterally. The capsule was identified. Linear capsulotomy wasplaced. 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 afocal area of degenerative change in the midportion of the metatarsal head cartilaginousarea, along with a corresponding area of bony overgrowth of the base of the proximalphalanx dorsally. Sagittal saw was used to remove all bony prominence. Ronguerwas used to remove bony prominence at the base of the proximal phalanx. Areaswere flushed with copious amounts of normal saline. A 0.45 K-wire was used tosubchondrally 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 bonemarrow protruding, indicated adequate depth of drilling. The area was flushed withcopious amounts of normal saline. The capsule was approximated using 3-0 Vicryl.The subcutaneous was reapproximated with 3-0 Vicryl. The skin was approximated with4-0 Nylon. Steri-Strip applied. Xeroform was mildly compressive dressing was applied.The patient tolerated the procedure well without any complications. Vascular statusreturned to normal levels. The patient returned to the recovery room in stable andapparent satisfactory condition. The patient was given postoperative instruction andprescription for pain meds.

Case Study # 4. Please assign the CPT code(s)-modifier(s)



for this case: ____________________________________________.

OPERATIVE REPORTPREOPERATIVE DIAGNOSIS1. Hallux rigidus with degenerative joint disease, first metatarsophalangeal joint, right foot.2. Exostosis with bursitis, fifth metatarsophalangeal joint, right foot.

POSTOPERATIVE DIAGNOSIS1. Hallux rigidus with degenerative joint disease, first metarsophalangeal joint, right foot.2. Exostosis with bursitis, fifth metatarsophalangeal joint, right foot.

OPERATION1. Cheilectomy with first metatarsophalangeal joint titanium hemi-implant, right foot.2. Exostectomy and bursectomy, fifth metatarsophangeal joint, right foot, with drainage of gouty tophus.

ANESTHESIAIntravenous sedation with local consisting of a total of 22 cc of 0.5% plain Marcaine.

HEMOSTASISPneumatic ankle tourniquet, right ankle, inflated to 250 mmHg for a total of 66 minutes.

COMPLICATIONSNone.

ESTIMATED BLOOD LOSSLess than 5 cc.

MATERIALSize 3 titanium hemi-implant.

INJECTABLES1. Intravenous Ancef, 1 gm, preoperatively.2. Local infiltration of 1 cc Decadron (4 mg), postoperatively.

SPECIMENSNone.




PROCEDURE:72 year old male was identified in the preoperative holding area and was taken to theoperating room. He was placed on the operating room table in the supine position. Afterobtaining intravenous sedation, the right foot was locally infiltrated with a total of 20 ccof 0.5% plain Marcaine. The right foot was then prepped and draped in the usual sterilefashion. After elevation and exsanguination of the right lower extremity, the tourniquetwas elevated to 250 mmHg.

Attention was then directed to the dorsal aspect of the right foot over the firstmetatarsophalangeal joint. A linear incision was made, approximately 6 cm in length,and carried down through the skin and subcutaneous tissue with sharp and bluntdissection. The vital neurovascular structures were avoided during the dissection andhemostasis was maintained with electrocautery. The extensor tendon was identified andlaterally 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 thefirst metatarsophalangeal joint, including the metatarsal head. A sagittal saw was usedto remove the degenerative bone and hypertrophic bone from the dorsal, lateraland medial aspects of the bone. A rongeur and hand rasp were used to provide asmooth contour and normal anatomic shape. The sagittal saw was again used to resectthe 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 coreout the medullary canal at the base of the proximal phalanx. The sizer was placed andthis was noted to be adequate. This was then removed followed by a total irrigation ofthe wound and placement of the size 3 titanium hemi-implant. There was noted tobe a good, smooth range of motion at that time. The head of the first metatarsal wasthen fenestrated with a 0.45 Kirschner wire.

The capsule was debrided and redundant capsule was excised. This was thenrepaired using 4-0 Vicryl suture in a running fashion. The subcutaneous tissues were thenclosed and reapproximated using 4-0 Vicryl sutures in a simple interrupted fashion. Theskin was then reapproximated using 4-0 nylon in a running horizontal mattress fashion.

Attention was then directed to the dorsal lateral aspect of the fifthmetatarsophalangeal joint. There, a linear incision was made approximately 4 cm inlength. Sharp and blunt dissection was carried out, again avoiding all vital neurovascularstructures and maintaining hemostasis with electrocautery. The capsule was incised.At that time, significant inflammatory fluid and gouty tophus were expressed from thejoint. The capsule and periosteum were incised throughout the length of the incision,exposing the fifth metatarsal head. An exostosis was noted and resected with therongeur. A hand rasp was used to provide a smooth contour to the fifth metatarsal head.




The joint capsule was also debrided and the bursa was excised. All gouty tophuswas removed. The wound was flushed with sterile saline. The capsule was then closedusing 4-0 Vicryl sutures. The subcutaneous tissues were also closed using 4-0 Vicrylsutures. The skin was closed with 4-0 nylon sutures in a running horizontal fashion.




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 andplaced on the operating table in the supine position. Local anesthesia was obtained to thethird and fourth toes of the right foot using 5 cc of 0.5% Marcaine plain. The right footwas 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 transverseincision was made at the plantar crease with a #15 blade. Dissection was carried downto the contracted flexor tendons at the proximal interphalangeal joint. The tendonwas identified and incised. Attention was then directed to the distal interphalangealjoint, through the same incision to identify contracted flexor tendons and jointcapsule structures. Contracted structures were incised in a transverse manner andstretched. Flexor contracture deformity was released and the digit was able to be held in arectus position.

Advanced Clinic Podiatry



Attention was then directed to the fourth digit of the right foot, where a transverseincision was made along the plantar flexor crease at the proximal interphalangeal jointwith a #15 blade. Dissection was then carried down to the contracted flexor tendons atthe proximal interphalangeal joint, where the flexor tendon and contracted jointstructures were incised transversely releasing a flexor contracture. The incision wasdeepened distally to release the contracted structures at the distal interphalangealjoint, allowing the fourth toe to maintain a rectus position. Steri-Strips were applieddorsally to maintain the third and fourth toes in a rectus position. Plantar structures werecovered with adaptic soaked Betadine and gauze.

The patient tolerated the above procedures and anesthesia well and left the operatingroom with vital stable and neurovascular structure of the toes intact. Following a periodof postoperative monitoring the patient was discharged home under her ownrecognizance. Postoperative instructions were given to the patient and the patient wasinstructed to make a follow-up appointment for Tuesday April 8.



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 localanesthesia was affected with 1% Xylocaine at the base of the second toe. The toe wasobviously necrotic. A curvilinear incision was made from the dorsal to plantar in the firstwebspace around the second toe. The second toe was disarticulated from itsarticulation at the metatarsophalangeal joint. The bed of the toe was then fairlyirrigated; then closure was carried out. The subcutaneous dead space was closed using 2-0Vicryl and the skin closed using 4-0 nylon. There was ample bleeding during theoperation to be optimistic about the viability of the amputation site. The foot wasdressed in the sterile dressing and the patient returned to the recovery room in stablecondition.





DOB: (Age 68)Gender: F

Specimen(s) ReceivedA: left 2nd toe

Final DiagnosisGANGRENE LEFT SECOND TOE: Gangrene of skin and subcutaneous tissue.

*** Electronically Signed Out

Clinical History

Gangrene left 2nd toe

Gross DescriptionThe specimen is labeled “left second toe.”

The specimen is received in formalin and consists of a single toe measuring 5.0 cm fromthe 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 ventralaspect of the toe. Bone is submitted following decalcification. Representative sectionsare submitted.Multiple sections/3 cassettesRepresentative section submitted/hrm.




OPERATIVE REPORT

ASSISTANTNone.

PREOPERATIVE DIAGNOSISOsteomyelitis, right great toe.

POSTOPERATIVE DIAGNOSISOsteomyelitis, right great toe.

OPERATIONAmputation of the right great toe.

ANESTHESIAMonitored.

INDICATIONS:This 70-year-old white male developed chronic osteomyelitis of the right great toe whichhas not improved with medical care.

PROCEDURE/FINDINGSUnder intravenous sedation, a right ankle block was instilled with 1% Xylocaine and0.25% 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 theinterphalangeal joint. The condyles of the proximal phalanx were then resectedwith a rongeur. Bleeding was controlled with electrocautery. The wound was closedloosely with interrupted #3-0 nylon sutures. Sterile dressings were applied.The patient tolerated the procedure well and was taken to the recovery room insatisfactory condition.




OPERATIVE REPORT

PREOPERATIVE DIAGNOSISHammer toe, fifth toe, right.

POSTOPERATIVE DIAGNOSISHammer toe, fifth toe, right.

OPERATIONArthroplasty, fifth toe, right foot.

INDICATIONS: There was noted to be a focal dermal excrescence overlying the head ofthe 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 thepreoperative holding room to the operating room and placed on the operating table insupine position. Following induction of a local anesthesia, the right foot was preppedand draped in the usual sterile manner. The foot was then elevated to 60 degrees abovethe horizontal for purpose of exsanguination. An Esmarch dressing was wrapped tightlyabout the foot, the cuff was inflated to 250 mmHg, and the foot was lowered to theoperating table. The Esmarch dressing was removed. The following procedure wasperformed: Arthroplasty, fifth toe, right foot.

Attention was directed to the fifth toe where there was noted to be a focal dermalexcrescence over the dorsal lateral aspect of the fifth toe. Thus a 2.5 cm dorsal linearincision was made overlying the digit. The incision was deepened through sharp andblunt dissection. With attention being paid to all bleeders, which were cut, clamped,Bovied, and ligated as necessary. All vital structures were undermined, underscored, andthen were retracted medially and laterally for purpose of preservation, revealing theextensor digitorum longus tendon to the fifth toe, which was transected transversely atthe level of the proximal interphalangeal joint. The tendon and capsule were elevatedfrom their underlying osseous attachments, revealing the proximal phalangeal head. Itwas transected at the level of the surgical neck and extirpated from the wound intoto. All osseous prominences were rasped smooth at this time. The wound was flushedcopiously with sterile saline solution. Dissection was then carried over the lateral aspectof the middle phalanx. Utilizing a double-action bone-cutting forceps, the lateralaspect of the phalanx was transected longitudinally and extirpated from the woundin toto.



The wound was washed copiously with sterile saline solution. There was noted to be noosseous 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 andmaintained, utilizing 4-0 Vicryl with simple interrupted technique. The skin wascoapted and maintained utilizing 5-0 monofilament nylon with horizontal mattresstechnique. Then 0.25 cc of dexamethasone phosphate and 2 cc of 0.5% Marcaine wereinstilled through the surgical site. The foot was dressed with 4 x 4, Kling, and Coban, andthen the pneumatic ankle tourniquet was released. An instantaneous capillary refill wasnoted.




Pathology Report

Age/Sex: 23/F Location: AMB

PREOPERATIVE DIAGNOSISHammertoe 5th right toe

OPERATION PERFORMEDRight Arthrodesis Toe

TISSUE REMOVEDA. Bone, right 5th toe

GROSS DESCRIPTION

RECEIVED LABELED BONE, RIGHT SMALL TOE, ARE TWO PIECES OF PALEWHITE TO PINK, BONY FRAGMENT MEASURING 1.0 X 0.6 X 0.5 CM AND 0.5X 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 DEGENERATIVECHANGE CONSISTENT WITH HAMMER TOE REPAIR.

Signed ____________________ (signature on file) ________________________




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 thepatient was brought to the OR and placed in the classical Recumbant position. Afterachieving adequate IV sedation, local mixture was infiltrated. Attention was directed tothe left foot after being prepped and draped in the usual sterile fashion. Attention wasthen 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. Areaswere flushed with copious amounts of normal saline. Vascular status remained normal.The skin was reapproximated using 4-0 Nylon. Mildly compressive gauze dressing wasapplied. The patient was given postoperative instruction. The patient tolerated theprocedure well without any complications and will be followed up in our office.





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 DescriptionA. 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. Nohistologic sections are obtained; gross diagnosis only.

B. Received in formalin and labeled “Bone second digit, left foot” are two irregularfragments of gray-tan to yellow osseous tissue measuring in aggregate 1.5 x 1.4 x 0.5cm. No histologic sections are obtained; gross diagnosis only.

Electronic Signature




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 theoperating room and placed on the operative table in the supine position. Pneumatic ankletourniquets were then placed about both of patient’s ankles. Following IV sedation localanesthesia was obtained about both the feet utilizing 20 cc of 0.5% Marcaine plain. Thefeet were scrubbed, prepped, and draped in the aseptic manner. An Esmarch bandage wasutilized to exsanguinate the patient’s feet, and a pneumatic ankle tourniquet was theninflated on both ankles at the same time.




Attention was then directed to the right foot. On the second, third and fourth digits ofthe right foot two converging 2 cm semi-elliptical transverse incisions were madeover the dorsal aspect of the these digits. The incisions were centered over the distalinterphalangeal and encompassed the dorsal callous present at the distal interphalangealjoint. The incisions were deepened through the subcutaneous tissue, with care beingtaken to identify and retract all vital neural and vascular structures. The ellipses of skinwere removed in toto utilizing sharp dissection. All bleeders were cauterized and ligatedas necessary.

At this time a transverse tenotomy and capsulotomy was performed to the distalinterphalangeal 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 passedfrom the operative site. The wounds were flushed with copious amounts of sterilenormal saline. The extensor tendon was re-approximated and coapted utilizing 3-0Vicryl 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 cmsemi-elliptical transverse incisions were made over the dorsal aspect of this digit.The incisions were centered over proximal interphalangeal and encompassed the dorsalcallous present at the proximal interphalangeal joint. The incisions were deepenedthrough the subcutaneous tissue, with care being taken to identify and retract all vitalneural and vascular structures. The ellipse of skin was removed in toto utilizing sharpdissection. All bleeders were cauterized and ligated as necessary.

At this time a transverse tenotomy and capsulotomy was performed to the proximalinterphalangeal joint of the fifth digit of the right foot. The head of the proximalphalanx was freed of its capsular and ligamentous attachments. Next, utilizing the bonesaw, the head of the proximal phalanx was resected and passed from the operativesite. The wound was flushed with copious amounts of sterile normal saline. Theextensor tendon was re-approximated and coapted utilizing 3-0 Vicryl and the skinwas reapproximated and coapted utilizing 5-0 nylon using simple interrupted suturetechniques.

Upon completion of the procedure a total of 1.5 cc of dexamethasone was infiltratedaround the incision sites. The incisions were dressed with Betadine soaked adaptic andcovered with sterile compressive dressings consisting of 4 by 4s and Kling. Thepneumatic tourniquet was deflated and a prompt hyperemic response was noted to alldigits of the right foot. An Ace wrap and postoperative shoe were then applied.




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 dorsalaspect of the these digits. The incisions were centered over the distal interphalangeal andencompassed the dorsal callous present at the distal interphalangeal joint. The incisionswere deepened through the subcutaneous tissue, with care being taken to identify andretract all vital neural and vascular structures. The ellipses of skin were removed in totoutilizing sharp dissection. All bleeders were cauterized and ligated as necessary.

At this time a transverse tenotomy and capsulotomy was performed to the distalinterphalangeal 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 andpassed from the operative site. The wounds were flushed with copious amounts ofsterile normal saline. The extensor tendon was re-approximated and coapted utilizing3-0 Vicryl and the skin was re-approximated and coapted utilizing 5-0 nylon using simpleinterrupted suture technique.

Attention was then directed to the fifth digit of the left foot. Two converging 2 cmsemi-elliptical longitudinal incisions were made over the dorsal aspect of this digit.The incisions were centered over proximal interphalangeal joint and encompassed thedorsal callous present at the proximal interphalangeal joint. The incisions were deepenedthrough the subcutaneous tissue, with care being taken to identify and retract all vitalneural and vascular structures. The ellipse of skin was removed in toto utilizing sharpdissection. All bleeders were cauterized and ligated as necessary.

At this time, a transverse tenotomy and capsulotomy was performed to the proximalinterphalangeal joint of the fifth digit of the left foot. The head of the proximalphalanx was freed of its capsular and ligamentous attachments. Next, utilizing the bonesaw the head of the proximal phalanx was resected and passed from the operativesite. The wound was flushed with copious amounts of sterile normal saline. Theextensor tendon was re-approximated and coapted utilizing 3-0 Vicryl and the skinwas reapproximated and coapted utilizing 5-0 nylon using simple interrupted suturetechniques.

Upon completion of the procedure, a total of 1.5 cc of dexamethasone was infiltratedaround the incision sites. The incisions were dressed with Betadine soaked adaptic andcovered with sterile compressive dressing consisting of 4 by 4s and Kling. The pneumatictourniquet was deflated and a prompt hyperemic response was noted to all digits of theleft foot. An Ace wrap and postoperative shoe were then applied.




The patient tolerated the procedures and anesthesia well. The patient was transferred tothe recovery room with vital signs stable and vascular status intact to all digits of bothfeet. Following a period of postoperative monitoring the patient was discharged home onthe 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.




OPERATIVE REPORT

PREOPERATIVE DIAGNOSIS: 1. Bunion deformity, right foot. 2. Hammertoedeformity, right second digit.

POSTOPERATIVE DIAGNOSIS: Same.

OPERATION PERFORMED: 1. Osteobunionectomy with long V-arm with 2 screwfixation, right foot. 2. Extensor tenotomy, right second digit. 3. Flexor tenotomy, rightsecond digit.

ANESTHESIA: Local IV sedation.

Hemostasis with pneumatic ankle cuff at 250 mm of mercury for 90 minutes.

SPECIMEN: Bone and soft tissue.


PROCEDURE: The patient was seen. The chart was reviewed. The patient wasbrought back to the OR and placed in the classical Recumbant position after givingadequate IV sedation. The above mixture was infiltrated and pneumatic ankle cuff wasplaced on the right side at the malleolar level, but not inflated. Foot was prepped anddraped in the usual sterile fashion. Attention was directed to the right first MPJ, wherea 5 cm curvilinear incision was placed medial to the extensor longus tendon. Dissectionwas carried down to the subcutaneous tissue, being careful to avoid all neurovascularstructures. Extensor brevis tendon was identified and tenotomized sharply. The firstinterspace dissection was carried out. Lateral capsulotomy and adductor tenotomy wascarried out. Dissection was carried to the capsule medially. A linear capsulotomy wasmade in same plane as the incision. Next, the capsule was reflected from the firstmetatarsal. Sagittal saw was used to remove the dorsal osteophyte and also thedorsal medial prominence of the first metatarsal. Joint was examined to show thatthere was smooth cartilage present, with some are of yellowish, fibrous cartilage on thedirect center of the area, but intact. Next, the V-osteotomy was made with a long dorsalarm, 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, thecapsule fragment was distracted and displaced medially, approximately 3 to 4 mm andpacked.




Two 0.45 K-wires were placed on the dorsum to hold the osteotomy in place and two3.0 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 areaswere rasped smooth of any rough edges and the areas were flushed with copious amountsof 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 seconddigit, where an 11 blade was used to perform an extensor tenotomy and capsulotomyon the dorsum at the second MPJ. On doing so, unloading the foot, it was noted thatthe 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 carriedout. Upon doing so, the digit did hold in a rectus position. 4-0 Nylon was used on thedorsal and plantar incision, one each. Steri-Strips were applied. Mild compressivedressing was applied with Ace wrap. Vascular status returned to normal after deflatingtourniquet. The patient tolerated the procedure well without any completion. Thepatient 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 tofollow-up in our office for postoperative care.





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 DescriptionReceived in formalin and labeled - “Bone right great toe” is one flat fragment of pale whiteosseous tissue measuring 1.5 x 0.7 x 0.2 cm. No histologic sections are obtained; grossdiagnosis only.

Electronic Signature




OPERATIVE REPORT

PREOPERATIVE DIAGNOSIS: Severe recurrent hallux valgus deformity of rightforefoot.

POSTOPERATIVE DIAGNOSIS: Severe recurrent hallux valgus deformity of rightforefoot.

OPERATIVE PROCEDURE: Right hallux MP arthrodesis.

ANESTHESIA: General per Wood/C.R.N.A. with supplemental 0.5% plain Marcaineankle block per surgeon for postoperative analgesia.

TOURNIQUET TIME: Slightly over one hour at 300 mmHg.

DRAINS: None.


IMPRESSION: Percutaneous threaded K-wires.

DESCRIPTION OF PROCEDURE: After satisfactory general anesthesia wasestablished with the patient supine on the operating room table. The tourniquet was thenplaced on the right thigh. Ancef 1 gm IV had been administered. After successfulanesthesia was established, the right foot and ankle was prepped and draped to a sterilefashion. It was held elevated for several minutes. The tourniquet was inflated to 300mmHg.

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 proximalphalanx and off the metatarsal head and neck until adequate exposure of the jointsurfaces was gained. The articular surfaces were then removed with hand instruments.The subchondral base plate was left in place on the proximal phalangeal side, butperforated multiple times with a K-wire. Once adequate bone resection had beengained in order so as to allow reduction of the deformity, the threaded K-wires wereplaced on the base of the proximal phalanx out the end of the toe. The hallux wasthen positioned in proper location for fusion. The K-wires were passed into themetatarsal head. The bone was quite friable, but in spite of this, the fixation andappeared to be quite good. The wires were cut off and capped.




The wounds were irrigated and closure was obtained was obtained with interrupted 2-0Vicryl and 4-0 nylon for the skin. A 0.5% plain ankle block was put in place prior toskin closure. The patient was awakened from anesthesia and taken to the recovery roomin stable condition. No complications were encountered and counts were correct.

DISPOSITION: She will be discharged home following recovery from anesthesia withoffice follow-up next week. She has Tylox, #40, with no refill, for pain. She should keepthe dressing dry and foot elevated. She should weight bear on heel only and report anyinterim problems if they occur.



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 leftfoot.

POSTOPERATIVE DIAGNOSIS: Ganglion on the left foot and hallux valgus on the leftfoot.

OPERATION: Excision of the ganglion on the left foot and a simple bunionectomy onthe 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 thepreoperative holding area to the operating room and placed on the operating room table inthe supine position. Following the induction of intravenous sedation and regional localanesthesia, the left foot was prepped and draped in the usual sterile manner. The left footwas then elevated 60 degrees from the horizontal plane for the purpose of preoperativeexsanguination of the limb. During that three-minute time period of elevation, thepneumatic ankle tourniquet was applied to a well-padded site just proximal to bothmalleoli. The pneumatic ankle tourniquet was then elevated to a level of 250 mmHg forthe purpose of intraoperative hemostasis. The left lower extremity was then returned tothe operating room table. The remainder of sterile draping was completed. The followingprocedure was performed.

EXCISION OF GANGLION ON THE LEFT FOOT: Attention was directed to theleft foot, where there was a recurrent, non-resolving ganglion around the firstmetatarsophalangeal joint area of the left foot. Therefore, at this time, two semi-elliptical incisions were created over the dorsomedial aspect of the first metatarsal insuch a fashion to allow for removal of the ulceration in the skin which is part of theganglionic 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. Allcoursing venous tributaries were identified, clamped, cut, electrocoagulated, and ligated asnecessary. All vital neurovascular structures were identified, underscored, mobilized, andretracted from the incision site. This delivered into view a very thick, well-defined softtissue mass. The edges and periphery of the mass were identified and resected from




their surrounding tissue. Then that mass was removed completely from the surgicalsite and sent to pathology for both gross and microscopic examination. At the conclusionof this procedure, attention was directed to the first metatarsophalangeal joint area; andthe following procedure was performed:

SIMPLE BUNIONECTOMY OF THE LEFT FOOT: At this time, the previous skinincision was carried down to the level of the subcutaneous tissues, down into the areaof the capsular tissues over the first metatarsophalangeal joint. At this time, alinear capsulotomy was performed within the margins of the original skin incision. Thecapsular and periosteal tissues were then dissected free in one confluent layer bothmedially 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 aprominent first metatarsal head. The articulating cartilage was no longer effective. Muchof that had been destroyed. At this time, utilizing a sagittal saw, an osteotomy wascreated from dorsal to plantar, distal to proximal, through and through in such a fashionto remove that prominent bump of bone on the medial aspect of the firstmetatarsal. It should be noted that the bone was very soft and osteoporotic. That bonewas released from all remaining soft tissue attachments and extirpated in toto from thesurgical site. Attention was then directed to the osteotomized portions of bone thatwere rasped to a more smooth and even contour. The wound was flushed withcopious amounts of sterile saline solution, and attention was directed towards closure.The capsular tissues were recoapted and maintained utilizing #4-0 Vicryl in a simpleinterrupted fashion. The subcutaneous tissues were then recoapted and maintainedutilizing #4-0 Vicryl in a simple interrupted fashion. The skin structures were thenrecoapted and maintained utilizing #4-0 nylon in a simple interrupted fashion. Attentionwas then directed towards bandaging, where Adaptic, 3 x 3’s, 3 x 3 splints, a Kling, aKerlix and an Ace wrap were applied in a sterile, compressive and corrective fashion. Thepneumatic ankle tourniquet to the patient’s left foot was rapidly deflated, and normalinstantaneous capillary fill time was noted to return to digits one through five of thepatient’s left foot. The patient, having tolerated the surgery and anesthesia well, withvital signs stable and afebrile, was then transported from the operating room to the post-anesthesia recovery room for further monitoring.




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-metatarsalhead resection, left foot. Arthrodesis of the third, fourth and fifth digits, left foot, with0.45 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.


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 supineposition. After obtaining IV sedation, the left foot was anesthetized with a local ankleblock 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 250mmHg. Attention was then directed to the dorsal aspect of the firstmetatarsophalangeal joint on the left foot, where a dorsal longitudinal incision wasmade, approximately 6 cm in length. Chevron blunt dissection was carried avoiding vitalneurovascular structures and maintaining hemostasis with electrocautery. Dissection wascarried out down to the level of the first metatarsophalangeal joint capsule. The extensor



Case Study # 14 continuedtendon was identified and retracted laterally. A longitudinal incision was made to thecapsule and along the periosteum exposing the first metatarsophalangeal joint.Significant degenerative changes were noted, along with subluxation of the joint. Sagittalsaw was then used to resect the base of the proximal phalanx and also partialresection of the head of the first metatarsal. All bony irregularities were also removedwith rongeur and remodeled with sagittal saw and hand rasp. A complete lateralrelease was performed of the joint capsule in order to facilitate medial reduction ofthe hallux. Attention was then directed to the dorsal aspect of the thirdmetatarsophalangeal joint where a longitudinal incision was made approximately 3 cm inlength, extending to the base of the proximal phalanx. Again, sharp and blunt dissectionwas carried out avoiding vital neurovascular structures and maintaining hemostasis withelectrocautery. Dissection was carried out down to the level of the metarsophalangealjoint and the capsule was incised. A sagittal saw was used to resect the head of thethird metatarsal with the cut being oriented dorsal distal to the plantar proximal.Attention was then directed to the proximal interphalangeal joint of the third toewhere a transverse incision was made, approximately 1 cm in length. Dissection wascarried out to the level of the extensor tendon, which was then incised, at the level of thejoint, medial and lateral collateral ligaments were released, exposing the head of theproximal phalanx. This was resected with a sagittal saw, obtaining reduction of thehammertoe deformity. The cartilage on the base of the middle phalanx was then denudedwith sagittal saw and curette. At that time a 0.045 K-wire was driven in a retrogradefashion, across the proximal interphalangeal joint and then driven proximally into the thirdmetatarsal maintaining reduction of the hammertoe deformity andmetatarsophalangeal joint contracture. The dorsal incision over the third toe wasreapproximated with 4-0 nylon in a simple interrupted fashion. Subcutaneous closurewas performed over the third metatarsophalangeal joint with a 3-0 Vicryl in a simpleinterrupted fashion, followed by skin reapproximation with 4-0 nylon. Attention wasthen directed to the dorsal aspect of the fourth and fifth toe and metatarsophalangealjoint where the same procedures were then performed reducing the hammertoecontractor and resecting the fourth and fifth metatarsal head. Fixation andclosure was performed the same. At that time, attention was redirected back to firstmetatarsophalangeal joint, where retrograde fashion a 0.062 K-wire was placedthrough the hallux and then proximally into the first metatarsal maintainingreduction of the hallux valgus deformity. Capsular structures were closed using 3-0Vicryl in a simple interrupted fashion. The skin was then reapproximated with 4-0 nylonin a running horizontal fashion. Prior to closure, all wounds were irrigated copiously withsterile saline and Bacitracin solution. No procedure was performed to the secondmetatarsophalangeal joint or second toe, because this has been surgically removedin a previous surgery three to four years ago. All wounds were dressed withAdaptic, 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 andcapillary refill to the digits on the left foot.




The patient tolerated the procedure and anesthesia well. She was taken to recovery withvital signs stable and vascular status intact to the left foot. She has been givenpostoperative medications for pain control and instructions for no weightbearing on theleft foot. She will follow-up in my office in approximately 5-7 days.




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 specimenconsists of three pieces of pearl white to yellow and pink bony tissue fragment ranging insize 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 andcartilage with severe degenerative changes present. A few cartilaginous fragments,consistent with loose bodies, are identified, but histologic features diagnostic forrheumatoid arthritis are not identified.

Signed _________________ (Signature on file) ____________________________



VI. Sample CPT Audit Findings

Below are the written summaries provided to a Hospital after the author performed aCPT coding review of a sample of their ambulatory surgery cases in 2002:

Medical Record#: 1Discharge Date: 06/13/02

This Managed Care patient was seen for a second metatarsal osteotomy and a right fourthdigit arthroplasty, both of which were coded correctly as 28308 and 28285. However,the Tailor’s bunionectomy was inappropriately coded as 28296 (Correction of bunionwith metatarsal osteotomy). Please delete code 28296 and assign 28110 (Ostectomy,partial excision, fifth metatarsal head). Per the operative report for this case: “. . . thefifth metatarsophalangeal joint, where an approximate 4.5-cm linear incision was thenmade. . . fifth metatarsal . . . exostosis was resected in toto. . . an Austin-type osteotomywas then performed.”

A Tailor’s bunionectomy procedure involves a lateral longitudinal arthrotomy, in whichthe fifth metatarsophalangeal (MP) joint is exposed. The lateral prominence or exostosisof the metatarsal head is resected, and the capsule is tightly imbricated.


The Medicare patient was seen for a right hallux metatarsophalangeal (MP) arthrodesis,which was inappropriately coded as 28292 (bunion correction). Delete 28292 and assign28750-RT (Arthrodesis great toe, metatarsophalangeal joint). Per the operative report: “.. . flaps were developed off the base of the proximal phalanx and off the metatarsal headand 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 thetoe. . . the K-wires were passed into the metatarsal head. . . the fixation appeared to bequite good.”




The Commercial patient was seen for a radical bunionectomy with osteotomy, which wascorrectly coded as 28296. However, the first metatarsophalangeal (MTP) jointexostectomy was inappropriately coded. Please delete code 28288. Per the AmericanAcademy of Orthopaedic Surgeons (AAOS), code 28296 includes “removal of additionalexostoses in the area of the joint.”


The Medicare patient was seen for bilateral radical bunionectomy with osteotomy, whichwas coded as a unilateral surgery with code 28296. Please append bilateral proceduremodifier –50 to code 28296. Per the operative report: “Attention was then directed tothe dorsal aspect of the left foot, where a procedure identical to that described for theright foot was performed. . . “



VII. Case Studies Answer Key

Case Study 128080-RT

Case Study 228104-LT

Case Study 328289-LT

Case Study 428289-RT28899-RT28288-RT

Case Study 528272-T728272-T7-5928272-T828272-T8-5928234-T728234-T7-5928234-T828234-T8-59

Case Study 628820-T1





Case Study 928285-T128285-T2

Case Study 1028285-T128285-T228285-T328285-T428285-T628285-T728285-T828285-T9

Case Study 1128285-

Documents

Certificate of Attendance - hcmarketplace.comhcmarketplace.com/media/supplemental/2561_acmaterials.pdfCertificate of Attendance Advanced Clinic: Podiatry CPT Coding March 11, 2004