Key Pearls On Coding For Bunionectomies

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Anthony Poggio, DPM

   If the surgeon performs a Chevron (or other distal head osteotomy) procedure in the distal metatarsal head, a base wedge type procedure (both on the first metatarsal) and a phalanx osteotomy, this would amount to three osteotomies in three separate locations.

   In this case, the proper coding would be CPT 28299 to address the two first metatarsal osteotomies and then one would add CPT 28310 for the proximal phalanx osteotomy. It would not be proper to bill CPT 28299 and CPT 28298 for this three osteotomy combination as CPT 28299 and CPT 28298 would both overlap for the soft tissue joint or sesamoid work.

   In regard to a combination of a first MPJ release with a medial eminence type procedure and base wedge osteotomy of the first metatarsal, it is best to code this as CPT 28292 (for the MPJ work medical eminence resection) and use the metatarsal osteotomy code CPT 28306 for the metatarsal base work.

   If an osteotomy slips and requires a repeat procedure to fixate the displaced fragment, it is not proper to bill the repeat bunionectomy procedure. This is considered to be repair of a fracture. The proper coding would be either CPT 28476 or 28485, depending on how one addresses the dislocated first metatarsal osteotomy. If you perform a phalanx osteotomy as part of the bunion correction procedure, then code the correction of the displaced phalanx osteotomy as CPT 28496 or 28505.

   The above osteotomy codes specifically address the first metatarsal. One point of confusion can occur when one is performing a Chevron type osteotomy at the fifth metatarsal or any of the lesser metatarsals. The codes listed above specifically relate to the first metatarsal and not to the lesser metatarsals. One would best code any osteotomies at the lesser metatarsals with CPT 28308/28309.

Other Pertinent Insights

   Other areas of confusion that I have seen involve semantic differences between ostectomies and osteotomies. While simple removal of an exostosis does require the cutting of bone, it is not an osteotomy but rather an ostectomy. There are specific codes for ostectomies. Removing the medial eminence from the first metatarsal head is not an osteotomy nor is removing the lateral prominence from the fifth metatarsal head.

   To remove a bony prominence on lesser MP joints two, three or four, CPT 28288 would be the appropriate code to use. To remove a bony prominence on the fifth metatarsal head, one can use the specific code CPT 28110.

   Use the 28111-28114 procedure code series for removal of a complete lesser metatarsal head.

   Using a k-wire or similar device to drill into the head/base of a bone in an attempt to stimulate fibrocartilage in an arthritic joint is not payable separately but is included in the overall bunionectomy procedure. Use of cartilage plugs to repair cartilage defects may be deemed investigational by many carriers so one should attain preoperative authorization. There is no specific CPT code for that procedure so billing the unlisted code would be the most appropriate if the procedure is allowed.

In Conclusion

   As with any CPT code selection, you must adequately chart the procedure that you perform. Beyond the medicolegal reasons for accurate documentation, the chart will substantiate the procedure you performed and allow for proper processing of your claim. In addition, if the claim is denied or not processed correctly, the chart will serve as the basis for your appeal.

Dr. Poggio is a California Podiatric Medicine Association Liaison to Palmetto GBA J1 MAC and a medical consultant to several national health insurance and review organizations. He is a member of the American College of Podiatric Medical Reviewers and is board certified by the American Board of Podiatric Medicine and the American Board of Podiatric Orthopedics.

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Anonymoussays: February 18, 2010 at 4:29 pm

Does anyone have any idea why the 28292(Keller type) code pays more than the 28296 (Austin type with a V osteotomy and fixation)

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Anonymoussays: May 2, 2010 at 9:18 pm I found this article to be well composed and full of excellent coding information. Thank you for putting this information together. I would love to see Dr. Poggio write more articles. Thank you. Anita Reply to this comment »
Anonymoussays: June 4, 2010 at 12:58 pm

Great coding tool

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