11/11/2002    Jeff C. Kass, DPM

Hallux Limiting Billing

Query: Hallux Limiting Billing
From: Jeff C. Kass, DPM

How would one bill a case of cheilectomy of
First metatarsal (i.e. hallux limitus) where you
also removed hypertrophied bone at the base of
the proximal phalanx, examined the metatarsal
head and phalangeal base and found there to be
erosive changes at both sites so you subchondral
drill with .062 k-wire? Obviously this is all
done through one incision. Thanks in advance for
all help.

Jeffrey Kass DPM
Forest Hills, Ny
Jeffckass@aol.com

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[Codingline-L] Response:

While a number of literature articles define
a cheilectomy as an excision of dorsal spur and
dorsal 1/3 the metatarsal head, other articles
(and text references - Mann RA., Coughlin MJ.,
DuVries HL, Chang, T, Camasta, C, etc) simply
define a cheilectomy as resection of
proliferative bone at the metatarsal-phalangeal
joint.
CPT 28289 is defined as "hallux rigidus
correction with cheilectomy, debridement and
capsular release of the first metatarsophalangeal
joint". With the inclusion of "first
metatarsophalangeal joint" within the procedure
code definition, any removal of hypertrophied
bone at either the metatarsal head or the base of
the proximal phalanx would be included in the CPT
28289
allowance.
To support this, both CPT 28160 (hemi-
phalangectomy, proximal base phalanx) and CPT
28124 (exostectomy, partial, phalanx) are
considered by the Correct Coding Initiative list
of edits to be components of CPT 28289. Both CPT
28124 and CPT 28122 are also included in the list
of the global service for CPT 28289 by the
American Academy of Orthopaedic Surgeons. .
There is no CPT code for subchondral
drilling of the metatarsal-phalangeal joint (or
any place else on the foot). Considering the
point that both debridement and partial ostectomy
procedures of either, or both, the bones of the
first MTPJ are included in the allowance for CPT
28289, subchondral bone drilling of either bone
would be an optional modification of the primary
procedure, cheilectomy, and would be included in
the allowance for CPT 28289. It would not
additionally reimbursed.
If, however, the surgeon feels strongly that
the added difficulty involved in drilling
subchondral bone in the already exposed first
MTPJ goes significantly beyond what the makers of
CPT 28289 envisioned, the surgeon can always
attach a "-22" modifier to CPT 28289, submit a
detailed operative report, and increase his/her
billed amount for the procedure. Reality Check:
payers will review the operative report -
hopefully, using peer reviewers - and most likely
deny the additional reimbursement for the "-22"
modifier, but taking an additional 2-4 months to
do so. The payer, in wishing to further clarify
the billing, may reasonably request the surgeon
produce literature studies 1) that evidence that
subchondral drilling is the standard of care in
cases of hallux limitus (or rigidus) surgical
treatment, and 2) that evidence the significant
short term and long term efficacy of subchondral
drilling of the first MTPJ over non-subchondral
drilling of the first MTPJ in hallux limitus (or
rigidus) cases. The surgeon should be prepared
to produce a strong argument for the $1.47
additional the payer may ultimately give.

[Codingline-L] Expert Panelist: Harry
Goldsmith, DPM

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