Key Pearls On Coding For Bunionectomies

Given the common nature of bunionectomies, this author offers pertinent insights on coding for bunionectomies that involve the first metatarsal as well as coding for combination procedures.

   Bunion surgery can be difficult to code as there are many variations to each procedure. The key to billing the bunionectomy is to focus on the inherent procedure as opposed to one’s personal preference in regard to variations to the procedures, the use of specific fixation devices/material or even additional services.

   With this in mind, let us consider a few general points.

   In regard to fixation of a first metatarsal osteotomy, there is no variation in reimbursement if you are using a K-wire, screw, plate or other fixation devices. Payment is always based upon the inherent procedure you have performed and the standard of care. I have seen physicians attempt to bill the use of an external fixation device with certain bunion procedures. However, the fixation unit and the extra work involved would not be payable as that is more of a doctor preference of fixation choices and not necessarily the standard of care.

   Utilizing other types of materials to reinforce tendons or capsules may or may not be covered if this is not a common practice in performing the given bunionectomy procedure. Certain insurance carriers may have specific guidelines for the use of these materials.

   In regard to other “newer” devices/materials, such as those used to bind metatarsals together to decrease the intermetatarsal angles, these products are generally not covered by insurance companies. The rationale is that the use of these products is perceived as more of a personal preference of the physician and may be unproven in the literature.

   Keep in mind that “tendon transfers” involve an actual transfer re-routing of the tendon and not just simply reattaching a tendon a few millimeters to one side. These corrections generally occur at the joint level and work at the joint is considered part of the overall bunionectomy procedure. Keep in mind that the commonly billed tendon transfer code CPT 27690 is listed in the leg portion of the CPT book and not the foot section. Hence one should not use this code for forefoot “tendon transfers.”

   Since no bunionectomy would necessarily qualify as a standard bunionectomy, you must rely on the closest possible procedure when selecting your billing code. In the CPT book, especially in the professional edition, there are pictures included to provide an idea of how to code various bunionectomy procedures.

Mastering The Common Bunionectomy Codes

   Here are some common first metatarsal/bunionectomy CPT codes.

   CPT 28111. This code is for the complete resection of the first metatarsal head.

   CPT 28288. This code is for a partial ostectomy of a metatarsal head. There is no mention in the code descriptor as to which specific metatarsal this applies to. However, this code most commonly applies to the lesser metatarsals.

   CPT 28289. Similar in nature to CPT 28288, this code is specifically for the first metatarsal joint. This is the best code to use when one is performing a cheilectomy procedure to increase motion at the joint in order to address hallux limitus/rigidus. This procedure code also includes any capsular release the surgeon deems necessary, as well as dissection and removal of additional prominences on the base of the proximal phalanx that are jamming the joint.

   CPT 28290. This code describes a Silver-type (simple exostectomy) bunionectomy procedure. This would involve resecting the medial eminence. This code also covers releasing or excising the sesamoid.

   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.

   In this case, the proper coding would be CPT 28299 to address the two first metatarsal osteotomies and then one would add CPT 28310 for the proximal phalanx osteotomy. It would not be proper to bill CPT 28299 and CPT 28298 for this three osteotomy combination as CPT 28299 and CPT 28298 would both overlap for the soft tissue joint or sesamoid work.

   In regard to a combination of a first MPJ release with a medial eminence type procedure and base wedge osteotomy of the first metatarsal, it is best to code this as CPT 28292 (for the MPJ work medical eminence resection) and use the metatarsal osteotomy code CPT 28306 for the metatarsal base work.

   If an osteotomy slips and requires a repeat procedure to fixate the displaced fragment, it is not proper to bill the repeat bunionectomy procedure. This is considered to be repair of a fracture. The proper coding would be either CPT 28476 or 28485, depending on how one addresses the dislocated first metatarsal osteotomy. If you perform a phalanx osteotomy as part of the bunion correction procedure, then code the correction of the displaced phalanx osteotomy as CPT 28496 or 28505.

   The above osteotomy codes specifically address the first metatarsal. One point of confusion can occur when one is performing a Chevron type osteotomy at the fifth metatarsal or any of the lesser metatarsals. The codes listed above specifically relate to the first metatarsal and not to the lesser metatarsals. One would best code any osteotomies at the lesser metatarsals with CPT 28308/28309.

Other Pertinent Insights

   Other areas of confusion that I have seen involve semantic differences between ostectomies and osteotomies. While simple removal of an exostosis does require the cutting of bone, it is not an osteotomy but rather an ostectomy. There are specific codes for ostectomies. Removing the medial eminence from the first metatarsal head is not an osteotomy nor is removing the lateral prominence from the fifth metatarsal head.

   To remove a bony prominence on lesser MP joints two, three or four, CPT 28288 would be the appropriate code to use. To remove a bony prominence on the fifth metatarsal head, one can use the specific code CPT 28110.

   Use the 28111-28114 procedure code series for removal of a complete lesser metatarsal head.

   Using a k-wire or similar device to drill into the head/base of a bone in an attempt to stimulate fibrocartilage in an arthritic joint is not payable separately but is included in the overall bunionectomy procedure. Use of cartilage plugs to repair cartilage defects may be deemed investigational by many carriers so one should attain preoperative authorization. There is no specific CPT code for that procedure so billing the unlisted code would be the most appropriate if the procedure is allowed.

In Conclusion

   As with any CPT code selection, you must adequately chart the procedure that you perform. Beyond the medicolegal reasons for accurate documentation, the chart will substantiate the procedure you performed and allow for proper processing of your claim. In addition, if the claim is denied or not processed correctly, the chart will serve as the basis for your appeal.

Dr. Poggio is a California Podiatric Medicine Association Liaison to Palmetto GBA J1 MAC and a medical consultant to several national health insurance and review organizations. He is a member of the American College of Podiatric Medical Reviewers and is board certified by the American Board of Podiatric Medicine and the American Board of Podiatric Orthopedics.