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Code This!

Scenario Week of December 06, 2010:
View Current Scenario

Approach and Surgical Procedure:
The patient was brought in the operating room and placed in a supine position. General anesthesia was administered. Once adequate levels of anesthesia had been obtained, a time-out was called with the patient identification and the proposed procedure being agreed upon by the surgical team and operating room staff. The left foot was prepped and draped in the normal sterile fashion to include a pneumatic tourniquet placed about the left ankle.

Attention was directed to the lateral sinus tarsi region, where a 10 cm linear-type incision was made and deepened using blunt dissection. Bleeders were cauterized as necessary, and neurovascular structures were retracted medially and laterally as necessary. Dissection was carried out using blunt and sharp technique, revealing the subtalar joint. The capsule was incised, exposing the posterior and middle facets. Using an osteotome and mallet, the cartilage and subchondral plate was removed adequately to allow for eversion of the calcaneus, once fusion of the talus and calcaneus was achieved. The joint surfaces were prepared using a smaller osteotome for a shingling effect.

At this time, Trinity demineralized bone matrix was introduced into the joint space. An ICOS screw was introduced percutaneously through the dorsal aspect of the talar neck. This was placed through the neck and into the posterior aspect of the calcaneus. Under fluoroscopic guidance, it was noted that adequate compression of the subtalar joint was achieved. A MiniRail was then placed across the subtalar joint. Two pins were placed in the calcaneus, and two pins were placed in the body of the talus. Using the MiniRail compression system, it was noted that the joint was further reduced. Incision was closed deeply, taking care to reattach the capsular structures, followed by reapproximation of the peroneal tendon sheaths, using Vicryl suture. Subcutaneous tissues were reapproximated using simple interrupted Vicryl suturing. The skin was closed using a running locking Prolene suture. At this time, the surgical site was dressed with Xeroform, 4x4 gauze, Kling, Coban, and an Ace wrap.

The patient was taken to the postoperative care unit where vital signs were stable and intact. It was noted that neurovascular status of the left foot remained intact. Patient was discharged to home once he emerged successfully, without incident, from general anesthesia.


ICD-9-CM DIAGNOSES
Preoperative

715.97Ostoarthrosis, unspecified whether generalized or localized, ankle and foot
718.87Other joint derangement, not elsewhere classified, ankle and foot
726.79Other enthesopathy of ankle and tarsus

Postoperative

715.97Osteoarthrosis, unspecified whether generalized or localized, ankle and foot
718.87Other joint derangement, not elsewhere classified, ankle and foot
726.79Other enthesopathy of ankle and tarsus

Rationale
Since the degenerative joint disease documentation does not specify whether the condition is generalized or localized, code 715.97 should be assigned. Code 718.87 should be assigned for the joint instability. Peroneal tendon atrophy is classified as an other enthesopathy of ankle and tarsus.

ICD-9-CM OPERATIONS/PROCEDURES

81.13Subtalar fusion

Rationale
A specific code is available for subtalar fusion in ICD-9-CM; assign 81.13. Bone grafting and external fixation are both included in this code.

CPT PROCEDURES

28725-LTArthrodesis; subtalar (left side)

Rationale
Subtalar fusion is assigned to CPT code 28725, and since this particular case involved the left foot, modifier LT is appended to the code. Do not assign a separate code for the external fixation device application; there is a CCI edit and it should not be coded separately.

 
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