Question:
I'm not very experienced with the more difficult orthopedic cases. I'm getting just unlisted for the tendon transfers and not sure about the capsulorrhaphy. Can anyone help with this one? Any help would be appreciated.
POSTOPERATIVE DIAGNOSES: Left great toe cockup deformity and third crossover toe with dislocated MTP joint.
PROCEDURE: Left extensor hallucis longus to first metatarsal tendon transfer, extensor hallucis longus to extensor hallucis brevis tendon transfer, inspection of integrity of flexor hallucis brevis and then third toe MTP joint capsulorrhaphy and extensor tendon lengthening, flexor tendon to extensor hood tendon transfer.
ANESTHESIA: General plus local.
DESCRIPTION OF PROCEDURE: The patient was taken to the operating room, general anesthetic administered, airway secured, a well-padded thigh
tourniquet was applied. The leg aseptically prepped and draped in a manner to ensure a sterile field. Timeout process was completed. Attention
turned towards the third MTP joint. Longitudinal incision made, sharp dissection taken down through skin and subcutaneous tissue. A
Z-lengthening done on the extensor tendon. Deep capsular release performed to mobilize the metatarsophalangeal joint and release its contracture.
Attention then turned plantarly where a 2-incision approach was used to harvest the flexor long tendons from a distal incision, transfer them into a more proximal incision and then down to the extensor hood where they were tenodesed with 2-0 Vicryl. The extensor tendons repaired and ___ in position with 2-0 Vicryl. The skin closed with 2-0 Vicryl for the subcutaneous and nylon for the dermis. Attention turned towards the prior tibialis anterior repair, longitudinal incision was made through a previous incision site. Sharp dissection was taken down through skin and subcutaneous tissue. The tendon appeared to be tenodesed well into the medial cuneiform. The attention was then turned distally where her prior bunion incision was used, sharp dissection taken down through skin and subcutaneous tissue. The flexor hallucis brevis found to be attenuated but still functioning. The prior transfer of the flexor hallucis longus found to be intact. The extensor hallucis longus harvested the distal end tenodesed to extensor hallucis brevis with FiberWire. The proximal end shortened and then transferred through a drill hole in the first metatarsal and then secured back to itself using FiberWire. The wound was irrigated and closed with Vicryl and nylon. Sterile dressings and well-padded, well-molded 3-sided splint applied and the patient transferred to recovery stable, having tolerated the procedure well after local infiltration with 0.25% Marcaine plain.
Answer:
Joanne S:
Hi Tanesha,
This is a bit of a challenging note! This is my coding recommendation:
* I would have also used 28234, tenotomy, open, extensor, foot or toe, each tendon but it is a column 2 code for 28270.
I would be interested to see if anyone else would approach this differently!
Tanesha B:
Thanks Joanne for your help. Yes this was extremely challenging to put it mildly and working in the hospital setting doesn't make it any easier. My coworker whom is a lot more experienced than I am came up with the codes below but we're still not completely sure. I wish there was a comprehensive guide/book on these difficult orthopedic procedures. What do you or anyone else out there think of these codes?
I'm not very experienced with the more difficult orthopedic cases. I'm getting just unlisted for the tendon transfers and not sure about the capsulorrhaphy. Can anyone help with this one? Any help would be appreciated.
POSTOPERATIVE DIAGNOSES: Left great toe cockup deformity and third crossover toe with dislocated MTP joint.
PROCEDURE: Left extensor hallucis longus to first metatarsal tendon transfer, extensor hallucis longus to extensor hallucis brevis tendon transfer, inspection of integrity of flexor hallucis brevis and then third toe MTP joint capsulorrhaphy and extensor tendon lengthening, flexor tendon to extensor hood tendon transfer.
ANESTHESIA: General plus local.
DESCRIPTION OF PROCEDURE: The patient was taken to the operating room, general anesthetic administered, airway secured, a well-padded thigh
tourniquet was applied. The leg aseptically prepped and draped in a manner to ensure a sterile field. Timeout process was completed. Attention
turned towards the third MTP joint. Longitudinal incision made, sharp dissection taken down through skin and subcutaneous tissue. A
Z-lengthening done on the extensor tendon. Deep capsular release performed to mobilize the metatarsophalangeal joint and release its contracture.
Attention then turned plantarly where a 2-incision approach was used to harvest the flexor long tendons from a distal incision, transfer them into a more proximal incision and then down to the extensor hood where they were tenodesed with 2-0 Vicryl. The extensor tendons repaired and ___ in position with 2-0 Vicryl. The skin closed with 2-0 Vicryl for the subcutaneous and nylon for the dermis. Attention turned towards the prior tibialis anterior repair, longitudinal incision was made through a previous incision site. Sharp dissection was taken down through skin and subcutaneous tissue. The tendon appeared to be tenodesed well into the medial cuneiform. The attention was then turned distally where her prior bunion incision was used, sharp dissection taken down through skin and subcutaneous tissue. The flexor hallucis brevis found to be attenuated but still functioning. The prior transfer of the flexor hallucis longus found to be intact. The extensor hallucis longus harvested the distal end tenodesed to extensor hallucis brevis with FiberWire. The proximal end shortened and then transferred through a drill hole in the first metatarsal and then secured back to itself using FiberWire. The wound was irrigated and closed with Vicryl and nylon. Sterile dressings and well-padded, well-molded 3-sided splint applied and the patient transferred to recovery stable, having tolerated the procedure well after local infiltration with 0.25% Marcaine plain.
Answer:
Joanne S:
Hi Tanesha,
This is a bit of a challenging note! This is my coding recommendation:
- 27691 Left extensor hallucis longus to 1st metatarsal tendon transfer
- 27692-51 Extensor hallucis longus to extensor hallucis brevis tendon transfer
- 27692-59-51 Flexor tendon to extensor hood tendon transfer
- 28270-59-51 Capsulotomy, metatarsal-phalangeal joint with or without tenorrhaphy (Longitudinal incision made, sharp dissection taken down through skin and subcutaneous tissue. a Z-lengthening done on the extensor tendon. Deep capsular release performed to mobilize the metatarsal joint and release its contracture)
* I would have also used 28234, tenotomy, open, extensor, foot or toe, each tendon but it is a column 2 code for 28270.
I would be interested to see if anyone else would approach this differently!
Tanesha B:
Thanks Joanne for your help. Yes this was extremely challenging to put it mildly and working in the hospital setting doesn't make it any easier. My coworker whom is a lot more experienced than I am came up with the codes below but we're still not completely sure. I wish there was a comprehensive guide/book on these difficult orthopedic procedures. What do you or anyone else out there think of these codes?
- 28208-XS - left extensor hallucis longus to first metatarsal tendon transfer, extensor hallucis longus to extensor hallucis brevis tendon transfer
- 28270-T2 -MTP joint capsulorrhaphy and extensor tendon lengthening
- 28313-T2 - flexor tendon to extensor hood tendon transfer