07/29/2002    David Davidson, DPM

Codes Bundled to CPT 28299

Query: Codes Bundled to CPT 28299
From: David Davidson, DPM

I billed a first metatarsal base osteotomy with
an Akin bunionectomy as CPT 28298 (correction,
hallux valgus - bunion - with or without
sesamoidectomy; by phalanx osteotomy) and CPT
28306 (osteotomy, with or without lengthening,
shortening or angular correction, metatarsal;
first metatarsal).

The insurance company bundled the two codes and
paid the procedures as CPT 28299 (correction,
hallux valgus - bunion - with or without
sesamoidectomy; by double osteotomy).

I asked for a review because I felt that CPT
28299 was for a double osteotomy, as exampled by
an Austin bunionectomy and an Akin osteotomy. My
codes were for an Akin bunionectomy (distal) and
a proximal first metatarsal osteotomy - a more
complex procedure. I feel it is important to
appeal this decision otherwise it will
become "the law of the land" unless it is
changed. I need help with my appeal. Does anyone
have any thoughts? Thank you.

David Davidson, DPM
Buffalo, NY

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Codingline(L) response:

We have had several posted messages regarding
the change in the 2002 CPT description of CPT
28299 to "correction, hallux valgus (bunion)
with or without sesamoidectomy; by double
osteotomy" and exampled by 1) a bunionectomy
double osteotomy - proximal and distal - of the
first metatarsal and 2) a bunionectomy with
distal first metatarsal osteotomy and a proximal
hallux phalanx osteotomy.

In your scenario, you performed a hallux valgus
(bunion) correction with a double osteotomy -
one at the proximal first metatarsal and the
second at the proximal hallux phalanx.

The clarification of the "double osteotomy" by
example in the 2002 CPT would, in my opinion,
include your variation of the "double osteotomy"
theme. With the examples (illustrations) given,
the "double osteotomy", again, in my opinion,
can include any double osteotomy variation
bunionectomy on the first ray. Please
understand that my opinion changed with the 2002
CPT change.

In terms of complexity, I would probably argue
that the relative complexity in performing
an "Akin-type" bunionectomy with a first
metatarsal base osteotomy is no greater than
performing an "Austin-type" bunionectomy with a
first metatarsal base osteotomy (CPT 28299).

I believe the payer was correct in their
determination, and this would not be worth
appealing to the payer. Just my opinion.

Harry Goldsmith, DPM – Codingline(L) Expert

Other messages in this thread:

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08/01/2002    Harry Goldsmith, DPM

Codes Bundled to CPT 28299 (Shay Fish, DPM)

RE: Codes Bundled to CPT 28299 (Shay Fish, DPM)
From: Harry Goldsmith, DPM

Dr. Fish, it is a FACT that CPT 28299 represents
both a bunionectomy with double 1st metatarsal
osteotomy (Logroscino-type) and an Austin-Akin
type bunionectomy. That is the "law of the
[CPT] land". That definition was the result of
work by the AMA CPT Editorial Panel with input
from the AMA CPT Advisory Committee. While
specialty associations have opportunities to
supply their opinions on coding matters, their
input is not always enough to change the AMA CPT
Editorial Panel's decision.

As far as the degree of relative difficulty
between performing a 1st metatarsal base-wedge
osteotomy versus a proximal hallux phalanx
osteotomy, no one will argue that the phalangeal
osteotomy is equivalent to a 1st metatarsal
proximal osteotomy in terms of work, "real"
difficulty, risk, follow-up care...or our
individual perceptions of the procedures' value.
Ultimately, it is CMS that assigns Medicare
value for this codes. And many non-Medicare
payers use Medicare values in formulating their
fee schedules.

While most of us are not pleased with the CPT
28299 definition equating value of a Logroscino
bunionectomy to an Austin-Akin bunionectomy, it
is currently the "law of [CPT] land". The only
way to change it is to encourage the APMA Coding
Committee to submit a request for definition
change, or individually submit a request for
coding change to the AMA CPT Editorial Panel.
Until then you will have to deal with the
nonsense.

Harry Goldsmith, DPM
Cerritos, CA
hgoldsmith@codingline.com

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07/31/2002    Shay Fish, DPM

Codes Bundled to CPT 28299 (D. Davidson, DPM, H. Goldsmith, DPM)

RE: Codes Bundled to CPT 28299 (D. Davidson,
DPM, H. Goldsmith, DPM)
From: Shay Fish, DPM

In regards to Dr. Goldsmith's opinion and
remarks on coding 28299 for an Akin and a base
wedge osteotomy. I believe this scenario
glaringly illustrates some of the nonsense in
CPT code definition and RVU determinations.
Anyone who has trained residents can tell you
that the base wedge osteotomy is not only more
difficult to perform, but requires a more
lengthy and risky postoperative management
period.

Anatomically, the Chevron/Austin osteotomy is
not challenged by the proximity of the
dorsomedial cutaneus nerve, the deep peroneal
nerve or the deep plantar artery to the plantar
arterial arch; it does not require maintaining a
lateral hinge; it does not typically require
templating the amount of medial wedge to me
removed; it does not require the extra
instrumentation of bone clamping while fixating;
it does not require 6 weeks of postoperative
casting with all the inherent risks thereof; it
does not require more from the patient; the
little imperfections are more noticeable in the
base wedge and so are the litigious
possibilities.

This was the procedure I'd sweat while
instructing residents. And for all that
additional effort and management one earns just
over one additional RVU! I agree with Dr.
Davidson. Please help prevent this nonsense from
becoming “the law of the land'”

Shay Fish, DPM
Springfield, IL
FishDPM@aol.com

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07/30/2002    Barry Mullen, DPM

Codes Bundled to CPT 28299 (D. Davidson, DPM, H. Goldsmith, DPM)

RE: Codes Bundled to CPT 28299 (D. Davidson,
DPM, H. Goldsmith, DPM)
From: Barry Mullen, DPM

While the new 2002 CPT version bundles base
wedge osteotomies with any 2nd osteotomy on the
1st ray as 1 procedure, I'd be surprised if
there's one podiatrist in the world who doesn't
think the work, performance & associated
complication & morbidity are greater with the
proximal-based osteotomies. That increase should
ultimately be reflected in the RVU allotment and
whomever
has assumed negotiating power w/in our
profession to try & influence those who set the
fees should be pursuing this & the many other
discrepancies that continue to exist in the CPT
system

Barry Mullen, DPM
Hackettstown, NJ
YAZY630@aol.com