icd-9 as it pertains to outpatient coding · fun foot facts •your feet have ¼ of all the bones...

Pathological Conditions of the foot Copyright 2013

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The Speakers

• James Pfeiffer MAML, CCS, CPC

– James Pfeiffer has over 17 years of private industry and consulting experience in health care. He specializes in the areas of Revenue Enhancement for Hospitals and Outpatient Coding Compliance and education. He is passionate about the HIM industry and has taught as an adjunct faculty member at PHSC as well as mentoring future HIM colleagues.

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Disclaimer

• James Pfeiffer has prepared this program using official

Centers for Medicare and Medicaid Services (CMS) documents, Federal Register and recognized input from the Cooperating Parties. Every reasonable effort has been made to ensure the program’s accuracy. Never-the-less, the ultimate responsibility for correct use of the information lies with the user.

3 © 2013 KForce Healthcare, Inc Proprietary and Confidential


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Objectives

• Foot Anatomy

• Common Foot Disorders

• Overview of ICD-10 and CPT Coding for Common Procedures

• Modifiers

• Questions

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Fun Foot Facts

• Your feet have ¼ of all the bones in your body – 52 bones!

• The foot is an intricate structure containing 26 bones with thirty-three joints, 107 ligaments, 19 muscles and multiple tendons that hold the structure together and allow it to move in a variety of ways.

• There are approximately 250,000 sweat glands in a pair of feet, and they excrete as much as half a pint of moisture each day.

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The Bones of the Foot

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The Ligaments of the Foot

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Tendons of the Foot

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Common Disorders of the Foot • Hallux Valgus (acquired) ICD-10 M20.1x

– Result for extrinsic pressures on the foot which over time creates anatomical variance and likewise pain.

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Common Disorders of the Foot • Hallux Rigidus (acquired) ICD-10 M20.1x

– Called “stiff toe” usually results from bone spurs and various forms of arthritis characterized by rigidity of the big toe

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Common Disorders of the Foot • Hallux Varus (acquired) ICD-10 M20.3x

– The Big toe deviates away from the foot (hence varus) commonly caused by a failed bunion surgery however, can be caused by trauma and some forms of arthritis

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Common Disorders of the Foot • Hammer toe (acquired) ICD-10 M20.4x

– A sometimes painful Contracture or bending of the toe at the 1st joint of the phalanges (PIP), caused by extrinsic factors which unbalances the foot, also can be caused by trauma or arthritis.

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Common Disorders of the Foot

• Pes Planus-Flat Foot ICD-10 066.5x

– A congenital (066.5x) or acquired (M21.4x) where the anatomical arch of the foot is abnormal resulting in improper stride and anatomical range of motion which can cause mechanical stress on other lower limb joints.

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Common Disorders of the Foot

• Achilles tendon ICD-10 086.00x,01x,02x (A, D, S, initial, subsequent, sequela) – A traumatic or non-traumatic condition where the Achilles tendon ruptures

causing a deranged anatomical motion of the foot and pain. In I-10 broken down into injury, strain and laceration (codes in sequence above) and rupture spontaneous (extensor tendon) of the ankle and foot is in ICD-10, M66.37x.

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Common Disorders of the Foot • Ingrown Toenails ICD-10 L60.0

– Ingrown toenails sometimes necessitates surgical intervention

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Bunionectomy

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Coding for Bunionectomy’s

• This consititues CPT code ranges from 28290-28299 – In all these procedures areas of either the metatarsal bone and/or the phalanx are

either cut (otomy) or resected (ostectomy) its important to successfully distinguish the respective anatomical areas based on the operative reports, one important piece of advice comes from the CPT Assistant January 2007 Page 31: • “All of the codes in the 28290-28299 series include the following procedures when performed at the

first MTP joint: capsulotomy, arthrotomy, synovial biopsy, neuroplasty, synovectomy, tendon release, tenotomy, tenolysis, excision of medial eminence, excision of associated osteophytes, placement of internal fixation, scar revision, articular shaving, and removal of bursal tissue. These are integral components of the operation and are not to be reported separately”

• Coders are recommend to familiarize themselves with their respective providers operative report description, for instance a provider may indicate a Keller-type procedure without naming it a “Keller” type of operation.

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Example of what type of Bunion repair?

• After making an incision in the first MTP joint where a linear capsulotomy was performed allowing exposure to the first MTP joint. There was evidence of large erosive change along the articulating cartilage of the first metatarsal and hypertrophy of the dorsal medial eminence was clearly noted. A power sagittal saw was utilized to remove the hypertrophied dorsal medial eminence in toto. Any sharp edges were then ronguered and rasped as necessary. Due to the degenerative joint changes as well as the osteophytic area along the laterabases of the proximal phalanx, the base of the proximal phalanx was resected with a power sagittal saw performing the arthroplasty. Any sharp edges were then rasped as necessary. Care was taken to avoid the long flexor tendon. The wounds were then flushed repeatedly with sterile saline. As the hallux noted in good alignment , I did not proceed with K-wire fixation.

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Example of what type of Bunion repair?

• ANSWER:

–CPT 28292 – Keller, McBride or Mayo. The resection of the base of the proximal phalanx identifies this as a Keller bunionectomy.

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Bunion Correction

Brief overview of most common types of bunion or Hallux Valgus Repairs- – CPT 28293 - Resection of the joint with an implant

– CPT 28294 – soft tissue correction (Joplin). The correct alignment is achieved through tendon transfer rather than bone correction.

– CPT 28296 – with proximal metatarsal osteotomy (Mitchell, Chevron, Austin, Akin)

– CPT 28299 – with double osteotomy. For severe deformity, a double osteotomy of the metatarsal or osteotomy of the metatarsals and proximal phalanx may be necessary

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CPT Assistant Review

CPT Assistant December 2010 page 12

Question:

What CPT code(s) should be reported for a hallux valgus repair performed using a modified McBride bunionectomy technique and a Ludloff osteotomy?

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• Answer: Code 28292, Correction, hallux valgus (bunion), with or without

sesamoidectomy; Keller, McBride, or Mayo type procedure, and code 28306, Osteotomy, with or without lengthening, shortening or angular correction, metatarsal; first metatarsal, should be reported. Because the Ludloff osteotomy is primarily a metatarsal mid-shaft to base osteotomy, modifier 59, Distinct Procedural Service, should be appended to code 28306 to indicate that a separate and distinct procedure was performed. Since code 28292 does not include phalangeal osteotomy to correct deformity, proximal first metatarsal osteotomy, or ankle tendon lengthening, these procedures are separately reportable. Integral components of the bunionectomy procedure represented by code 28292 include capsulotomy, arthrotomy, synovial biopsy, neuroplasty, synovectomy, tendon release, tenotomy, tenolysis, excision of medial eminence, excision of associated osteophytes, placement of internal fixation, scar revision, articular shaving, and removal of bursal tissue. Code 28296 describes a bunion repair with a distal metatarsal osteotomy, therefore, it is not appropriate to report code 28296 for a bunionectomy with a proximal metatarsal osteotomy.

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What type of correction?

• A linear capsular incision was made directly to the level of the first MTP joint. The perisoteal and capsular structures were then carefully dissected allowing exposure to the first MTP joint where there was evidence of severe degeneterative joint disease and several loose osseous fragments. Utilizing the combination of power sagittal saw and rongeur, significant cheilectomy was performed along the first MTP joint to allow exposure to the first MTP joint. Next the power sagittal saw and power bur were utilized to remove the articulating cartilage from the first MTP joint to facilitate arthrodesis. The wound was flushed repeatedly with sterile saline. The first MTP joint was then placed into the appropriate alignment for artrodesis. A 0.062 K-wire oriented from proximal medial to distal lateral and proximal lateral to distal medial was then utilized in cross fashion to maintain the first MTP joint in excellent alignment and apposition for arthrodesis. The two proximal K-wires were then cut and tapped into the first metatarsal. The wound was then closed in a sterile fashion.

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Answer

• ANSWER:

– 28289 Hallux Rigidus correction with cheilectomy, debridement and capsular release of the first metatarsophalangeal joint.*

– *CPT Assistant, November 1998 page 11 • Cheilectomy has become a widely used procedure to manage the

problems associated with hallux rigidus. Code 28289 has been added to accurately report this procedure, while code 28122, previously used to report this procedure, has been appended with an explanatory reference note and has been altered as an indent code below code 28120.

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What type of operation?

• An incision was made over the second MTP join. The incision was deepened by sharp and blunt dissection carried down into the level of the extensor digitorum longus tendon which was lengthened in a Z plasty fashion. Dissection continued exposing the head of the proximal phalanx. Utilizing a power sagittal saw, the head of the proximal phalanx of the second tow was resected in toto. This resulted in good reduction of the hammer toe deformity. Due to the contracture a second incision within the capsule of the MTP joint capsulotomy was performed dorsally, medially and and laterally allowing the second toe to lie in a much better rectus position.

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Hammertoe operation

• CPT code 28285, Correction, hammertoe, is appropriately reported for all hammertoe corrections. The code descriptor for CPT code 28285 intentionally does not specify which interphalangeal joint is involved in the correction (ie, distal, proximal, middle) procedure. Therefore, CPT code 28285 is reported to represent the repair of several deformities that are referred to as “hammertoes”

-Coding Clinic for HCPCS 3rd Quarter 2010

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CPT Assistant September 2010 page 9

Question: • CPT codes 28285, 28270, and 28234 were all reported for surgery on a

single toe. Are the procedures reported by codes 28270 and 28234 included in code 28285?

Answer: • Code 28234, Tenotomy, open, extensor, foot or toe, each tendon, is

included when code 28285, Correction, hammertoe (eg, interphalangeal fusion, partial or total phalangectomy), is reported. Code 28270, Capsulotomy; metatarsophalangeal joint, with or without tenorrhaphy, each joint (separate procedure), is not included in code 28285 and is reported separately when performed.

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Pes Planus or Flat Foot

• Several types of corrective procedures – The goal is to correct the anatomical flat foot, this can involve bone grafts

(separately reported if from separate sites, tendon transfers, etc) • The operative report should fully describe the type of procedures performed

– 28730- Arthrodesis of the midtarsal or tarsometatarsl, multiple or transverse • 28735 with osteotomy (eg flat foot procedures) – in this case the respective shafts of the

metatarsals are cut, rearranged, joints debrided and then fused

• Its important to note in the above operations more than one of the midtarsal or tarsometatrsal joints are fused.

– 28899 (CPT) and HCPCS Temporary Code S2117- Arthroereisis, subtalar • A relatively new procedure whereas a subtalar implant is inserted that corrects the anatomical flat

foot

• Since no listed CPT code is applicable use 28899 for Medicare and HCPCS Temporary Code S2117 is reported for non-Medicare (validation with 3rd party payers is recommended)

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• AAOS states included in 28735 would be:

– preparation and insertion of synthetic bone substitutes, osteoconductive and osteoinductive agents

– tenolysis and/or tenosynovectomy, except for a different pathologic diagnosis

– internal and/or external fixation

– arthrotomy

– capsular release, repair, or reconstruction

– synovial biopsy 30


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• Procedures NOT included in 28735 would be:

– harvesting of graft through separate skin or fascial incision, distant site

– tendon lengthening

– tenolysis and/or tenosynovectomy for a different pathologic diagnosis

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Achilles Repair

• First determine whether it was non-traumatic and/or non-traumatic and if this was the primary or secondary repair

– 27650-Repair, primary, open or percutaneous, ruptured Achilles tendon;

• 27652- Repair, primary. Open or percutaneous, ruptured Achilles tendon, with graft

• 27654-Repair, secondary, Achilles tendon, with or without graft

– Other Achilles operations involve tenotomy (27605/27606), lengthening (27685 single, 27686 multiple)

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Hallux Varus Repair

– These repairs can be performed via a variety of means, such as osteotomy, reconstruction, an example of this would be in 28306 Osteotomy, with or without lengthening, shortening or angular correction, metatarsal, first metatarsal- the metatarsal shaft and a portion of the bone is removed in order to correct the alignment of the bone. Wires are used to reattach the bone in its corrected alignment. Sutures are use to close the incision. Report 28308 if the procedure is performed on other metatarsal bones.

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Subtalar Arthrodesis

– Subtalar Arthrodesis is used to correct typically severe forms of arthritis of the hind foot, or previous fractures of the talus or calcaneus, this is usually used as a last resort since the fusions may decrease mobility of the foot joints. In the following clip you will see the subtalar arthrodesis performed -28725, notice the various steps within the clip, the initial X-ray displays the DJD of the foot, followed by the incision, osteotomy and ostectomy, fusion and fluoroscopic fusion verification.

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Subtalar Arthrodesis

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Inter-Digital Neuromas (Morton’s)

• A painful benign lesion of the plantar nerve ICD-10 G57.6x – Through surgical ligation the nerve is exposed and the neuroma legated

– CPT 28080 reported for a excision of each single neuroma

• This differs from excision of lesion, tendon, tendon sheath, or capsule CPT 28090

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Inter-Digital Neuroma Injections

• CPT 64455 (injection[s], anesthetic agent and/or steroid, plantar common digital nerve[s]) should be used when an injection of an anesthetic agent and/or steroid is used to treat an interdigital neuroma.

• CPT 64632 (destruction by neurolytic agent; plantar common digital nerve) should be used for an injection of a neurolytic agent (ex. Phenol, Alcohol, Glycerol, Hypertonic Saline, etc.) into an interdigital neuroma.

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Coding for Foot procedures • Coders should familiarize the specific anatomy of the foot for

starters, this will assist the coder in delineating the specific structures

• Once the anatomy is correlated, next focus on the specific pathological and anatomic conditions that affect the foot

• Finally understand the range of the respective operation that is being performed i.e. what areas is the provider operating on, what excisions, ostectomies, ostetomies are made. – What is the “goal” of the surgery

– Is there an acute or chronic condition causing this malady

– Pay attention to the various joints involved i.e.. MTP, PIP, Inter-tarsal space, etc..

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Toe Modifiers

-TA Left foot, great toe -T1 Left foot, second digit -T2 Left foot, third digit -T3 Left foot, fourth digit -T4 Left foot, fifth digit -T5 Right foot, great toe -T6 Right foot, second digit -T7 Right foot, third digit -T8 Right foot, fourth digit -T9 Right foot, fifth digit

-RT and LT- Metatarsal Repairs

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Modifiers

• Do not use modifiers TA – T9 with metatarsal CPT.

• Use modifiers -RT, -LT or -50 for bunion correction surgery codes. The hallux (big toe) is already indicated in the procedure, you only need to specify laterality.

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Resources & References

• CPT Book 2016

• Coding Clinic for HCPCS

• CPT Assistant

• Jones, Lolita M. "Coders Can Benefit from Bare Bones Podiatry Lesson." Journal of AHIMA 74, no.6 (June 2003): 62-65.

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Questions?

42 © 2013 KForce Healthcare, Inc Proprietary and Confidential


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Survey Monkey and Support

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• Cell 727-808-8605

• Thank you again for attending !!!!

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icd-9 as it pertains to outpatient coding · fun foot facts •your feet have ¼ of all the bones...

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