Key Pearls On Coding For Bunionectomies
CPT 28292. This code describes the classic Keller bunionectomy as well as the McBride bunionectomy. Included in this code are resecting the medial eminence and/or irregularities at the base the proximal phalanx. The code also includes utilization of K-wires to stabilize the hallux when performing the Keller bunionectomy. This procedure code would also include any additional soft tissue releases around the joint and first interspace and sesamoid release or excision.
CPT 28293. A first metatarsophalangeal joint (MPJ) implant falls under this code. This would include both a hemi- as well as a total implant. Some insurance companies are reviewing this code at this time as they are deeming first MPJ implants as investigational. I would preauthorize these procedures to make sure the insurer pays/covers not only for the procedure but more specifically for the implant itself as some of the implants can be quite expensive. Any first MPJ implant would qualify for the use of this code whether it is a hemi-, double-stem or two component types.
CPT 28294. This code involves a bunionectomy with a tendon transfer. This involves metatarsophalangeal joint work with a repositioning of the extensor tendon (i.e. the Joplin type procedure). One should not use this procedure to slightly reposition the extensor tendon in order to change the pull of the tendon as part of a soft tissue correction to the bunion procedure. The use of this code requires a formal tendon re-routing to the opposite side of the metatarsal head. Do not use this code to cover the use of various new devices to draw the first and second metatarsal together.
CPT 28296. The classic distal first MPJ osteotomy is covered in this code. Examples are the classic Chevron osteotomy as well as the Reverdin and concentric type of osteotomies, which we tend to perform at the head and shaft of the metatarsal. This code also includes various variations on the osteotomies including the Z-type osteotomies.
Although the classic Chevron osteotomy is a two-part osteotomy with two arms, this is still considered a single osteotomy. Even a bi-correctional Chevron is still considered a single osteotomy. While the Z-type osteotomy has three arms, it is still considered a single osteotomy. Fixation options of these osteotomies are the surgeon's preference and are not payable separately from the procedure allowance.
CPT 28297. This code describes the Lapidus type bunionectomy, which involves fusion at the first metatarsocuneiform joint. This procedure code also covers soft tissue joint work at the first metatarsophalangeal joint, including resection of the medial eminence.
CPT 28298. This code covers a bunionectomy in which the surgeon utilizes a phalanx osteotomy to correct the hallux. This procedure classically involves a medial eminence resection of the metatarsal head and a subsequent proximal or distal type hallux osteotomy (e.g. an Akin procedure).
Navigating The Maze Of Combination Procedure Codes
The following bunionectomies are more combination type procedures, which are more difficult to code.
CPT 28299. Since codes ending in XXX99 tend to be unlisted procedures, this code can cause difficulties for some insurance companies. However, this particular code does have an adequate description and is not truly an unlisted procedure. This code describes performing two osteotomies on essentially the first metatarsal and/or hallux in almost any combination.
In the CPT book, there are several pictures/descriptions to help clarify combination procedure coding. One of the common examples shown in the CPT book is a combination first metatarsal head and proximal phalanx osteotomy. These are two separate osteotomies. Another example is performing a distal head osteotomy and a base osteotomy. While both involve the first metatarsal, the osteotomies are in two separate areas. This would also qualify as a double osteotomy.
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.