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Scenario Week of June 01, 2012:
View Current Scenario

Preoperative Diagnosis: Infected right third toe open wound, nonhealing with exposed bone

Postoperative Diagnosis: Same

Procedure Performed: Amputation at the metatarsophalangeal joint of the right third toe

Anesthesia: Local MAC

History: The patient is a 65-year-old female with severe neuropathy to her right foot. She presented to my office with a foot infection resulting from an open wound to the third toe. Cellulitis and infection have resolved; however, the underlying wound remains with exposed bone. The patient presents today for amputation of the right third toe at the metatarsophalangeal joint.

Procedure: The patient was examined prior to the procedure. Risks, alternatives, and benefits were discussed and informed consent was obtained. The patient was taken to the OR and placed in the supine position. Local MAC anesthesia was administered. Upon adequate anesthesia, the patient’s right foot was prepped and draped in the usual sterile fashion. Preoperative antibiotics were ongoing. Sequential compression devices (SCD) were in place to the opposite leg. A time-out has been performed. The toe was then injected with local lidocaine. A fishmouth incision was made and the bone was taken down with rongeurs and the metatarsophalangeal joint was disarticulated allowing removal of the entire phalangeal bone and surrounding tissue. Nerves and vessels were tied off. Hemostasis was achieved with electrocautery. Deep tissue was then closed using an interrupted 3-0 Vicryl, followed by horizontal mattress stitches. A bulky dressing was applied. The patient tolerated the procedure well without complications and was taken to the recovery room in stable condition.

Code this!


CPT Code
28820–T7 Amputation, toe; metatarsophalangeal joint – right third toe

ICD-9-CM Code
893.1 Open wound of toe(s), complicated

In the CPT index, the coder would look under the main term “amputation” and select subterm “toe” which references to code range 28810–28825. Procedure code 28820 is selected because the documentation states the amputation occurred at the metatarsophalangeal joint. Modifier T7 is used to indicate the right third digit of the foot was amputated. Incidental severing of nerves and vessels are included in the amputation procedure.

The corresponding ICD-10-PCS code would be ØY6TØZØ Detachment at Right 3rd Toe, Complete, Open Approach. Detachment is defined by CMS as, “ICD-10-PCS Root Operation value 6. Cutting off all or a portion of the upper or lower extremities. The body part value is the site of the detachment, with a qualifier, if applicable, to further specify the level where the extremity was detached.” The ICD-10-PCS alphabetic index term “amputation” directs the user to detachment. The specific toe is referenced when searching under detachment, toe and verified in the tabular list. The seventh character is used to describe whether the amputation is complete (0), high (1), mid (2), or low (3). In this case the amputation is performed through the MTP joint; therefore, it would be considered a complete amputation of the toe represented by 0.

For the diagnosis code, the patient was diagnosed as having a nonhealing open wound with exposed bone. In the alphabetic index of ICD-9-CM (volume 2), under the main term “wound, open,” the subterm “toe” has two additional subcategories: with tendon involvement (893.2) and complicated (893.1). Note that guidance provided at the beginning of the section on open wounds states that it is not appropriate to assign a code designated as “complicated” simply based on the provider’s documentation; rather, for coding purposes, there must be indications of either delayed healing or treatment, infection, or the presence of a foreign body. In the above operative note, the physician has stated that previous infection has since resolved; however, he has also described the condition as nonhealing and due to the wound remaining open with exposed bone, this would be further evidence of “delayed” healing. Therefore, assignment of code 893.1 would be appropriate.

The corresponding ICD-10-CM code would be S91.1Ø4D Unspecified open wound of right lesser toe(s) without damage to nail, subsequent encounter. In ICD-10-CM the qualifiers are nail damage and great toe as opposed to lesser toe. The subsequent visit code would be selected as this is not the first encounter to treat the open wound. It would be inappropriate to report sequela at this encounter as this represents ongoing treatment of the open wound. It would be inappropriate to report resolved conditions of infection or cellulitis.

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