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Query: Lapidus vs. Midfoot Fusion

The physicians (in our practice) and I had an interesting discussion regarding the Lapidus procedure (CPT 28297). The physicians wanted to verify whether it is appropriate to bill CPT 28292 (Keller/McBride-type bunionectomy) with CPT 28297 (Lapidus-type bunionectomy) when rendering both services.

They also wanted to know the difference between billing the midfoot fusion vs. the Lapidus procedure. They are similiar codes with very different reimbursement. I can give them basic coding differences and CCI rules, but I wanted to get some feedback from other physicians.

Terri Phillips, CPC, Tulsa, OK

Response: Codes CPT 28290 - CPT 28299 are "bunionectomy" codes. Only one bunionectomy can be performed and billed per foot (anything else would be duplicate billing) by surgical procedure definition.

The different bunionectomy/hallux valgus correction codes represent variations on how (or to what extent) hallux valgus/bunion corrections are accomplished based on the presenting deformities. The Lapidus-type bunionectomy involves a metatarsal-cuneiform fusion plus a bunion correction. It is performed when there is 1) instability in the metatarsal-cuneiform joint, and/or 2) metatarsus primus adductus, and/or 3) arthritis in the metatarsal-cuneiform joint - and a bunion/hallux valgus deformity is present.

"Midfoot" is not a good term to use. Most - although not all - sources consider the "midfoot" to be the mid-tarsus area of the foot, not including the metatarsal-cuneiform joint (while the forefoot is considered the metatarsals and structures distally). It would be better to specify the involved joint.

If the 1st metatarsal-cuneiform joint is NOT being fused, then both procedures, Lapidus-type bunionectomy [CPT 28297] and "midfoot" fusion (CPT 28740 [arthrodesis, midtarsal or tarsometatarsal, single joint] or CPT 28730 [arthrodesis, midtarsal or tarsometatarsal, multiple or transverse], depending on what was done) could be separately billed.

If, however, the 1st metatarsal-cuneiform joint is being fused along with the performance of a bunionectomy procedure (non-osteotomy-type), then CPT 28297 would be the only code billed.

Harry Goldsmith, DPM, Cerritos, CA

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