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Code This!

Scenario Week of April 01, 2011:
View Current Scenario

The patient is a 59-year-old female with a two-year history of pain and swelling in her feet bilaterally that has gradually inhibited her ability to walk and to exercise. She has tried conservative measures including wrapping of the toes, injections, anti-inflammatory medications, and ice to no avail over the past eight months. She has hammertoes on the second through fifth toes of both feet and has elected to proceed with surgery for the correction of these deformities.

PROCEDURES PERFORMED: Hammertoe repair done on left and right 2nd, 3rd, & 4th toes as well as extensor tenotomy on bilateral 5th toes

DETAILS: The patient with bilateral second through fifth hammertoes admitted for correction. Right second, third, and fourth and left second, third, and fourth hammertoe corrections which included proximal interphalangeal (PIP) joint fusion, pinning, and extensor tenotomies were performed. In addition, extensor tenotomies were performed on the fifth toes of both feet without PIP joint pinnings and fusions. The procedures were tolerated well by the patient and she was discharged from the outpatient surgery department on the same day of surgery with careful instructions for wound care, activity, and follow-up care.

Assign the correct ICD-9-CM diagnosis code(s) and CPT code(s) to the scenario.

Codes and Rationale
ICD-9-CM Diagnosis Code

735.4 Other hammer toe acquired

Because the surgeon notes this condition has been progressive over the past two years, it is an acquired, rather than a congenital, condition and is reported with code 735.4.

CPT Procedure Codes

There are many types of procedures for the repair of hammertoes that may be performed alone or in combination with other procedures. The choice of procedure to perform depends on the structure of the foot, whether the deformity is rigid or flexible, the severity of the deformity, and the existence of coexisting foot and toe deformities. The operative procedure may involve the bone, joint, or soft tissues.

Based on the information provided in the operative note, code 28285 is the correct choice for the hammertoe repair procedures. As this code already includes the extensor tenotomy, fusion of the PIP joint, and pinning, no additional codes are necessary to report the hammertoe repairs performed on the second through fourth digits of both feet.

For the extensor tenotomy on the fifth toes, code 28234 (extensor tenotomy foot or toe, each tendon) would be appropriate. Do not confuse this code with 28225, which is for tenolysis of a foot extensor.

Assuming that each hammertoe on both feet was treated in the same way, and the payer wants the multiple procedures reported using the specific anatomic modifiers for the toes, report these surgeries as follows:

28285-T1
28285-T2
28285-T3
28285-T6
28285-T7
28285-T8
28234-T4
28234-T9

Although coding the procedures involved may be somewhat straightforward, that is not the only issue involved in getting payment for the claim. Some payers require documentation regarding the failure of conservative treatment for a period of time prior to the procedure. In addition, because coverage is not provided for any procedure purely for cosmetic reasons, functional issues (e.g., pain, swelling, inability to walk) involving the foot and/or toe must be clearly documented to demonstrate the medical necessity for the procedure. In addition, because surgery of the foot and toes often involves multiple procedures, it is necessary to report modifiers with the codes on the claim. It is a good idea to query the individual payer for its specific guidelines regarding the use of modifiers for surgical encounters that include multiple procedures as guidelines vary among local third party payers. Modifier options may include 50 Bilateral procedures, 51 Multiple procedures, 59 Distinct procedural service, and the specific HCPCS Level II modifiers TA through T9 that designate the particular digit in question on the right or left foot.

Regardless of which modifiers are used, it may be useful to submit an operative report as well, due to the many procedures performed and to prevent confusion on the part of the payer (and a subsequent denial).
 
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