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05/10/2002    From: Richard P. Mistretta, D.P.M.

Akin Osteotomy And 1st Metatarsal Osteotomy

Query: Akin Osteotomy And 1st Metatarsal
From: Richard P. Mistretta, D.P.M.

I performed an Akin osteotomy along with a
bunionectomy with an off-set "V" osteotomy of
the first metatarsal. I billed it as CPT 28296
and CPT 28310. The particular insurance company
re-coded it as a "double osteotomy", CPT 28299.
Is this reasonable?

I thought CPT 28299 referred to a Logroscino-
type procedure when the double osteotomy is
performed on different ends of the first
metatarsal bone. Clearly, the Akin osteotomy is
in the proximal phalanx (and addresses the
hallux abductus interphalangeus) while the
metatarsal osteotomy is in the first metatarsal
(and addresses the metatarsus primus

I have appealed the claim once, explaining the
purpose of the 2 procedures, but the insurance
medical reviewers came back and denied the CPT
28310 claim. Their decision (surprisingly) was

Is this acceptable now? Are phalangeal and
metatarsal osteotomies routinely bundled
together? If not, what is my next step in the
appeal process?

Richard P. Mistretta, D.P.M.
Duluth, GA


[Codingline-L] Response:

Prior to January 1, 2002, the recommendations of
most [Codingline-L] respondent to similar
questions were that the procedure should be
coded as CPT 28296 and CPT 28310-59
(or "TA"/"T5"). There was no official
direction from CPT. Third party payers,
however, had their own guidelines with some
allowing the CPT 28296/28310 set of codes, while
others bundled the two codes to CPT 28299
(bunionectomy with double osteotomy). Prior to
January 1, 2002, there was no clear definition
of what constituted a "double osteotomy" (i.e.,
where the double osteotomies were placed).

Beginning January 1, 2002, CPT modified its
definition of CPT 28299 and included 2 procedure
samples for the code. One case sample was a
bunionectomy with double osteotomy 1st
metatarsal (one distal, one proximal). The
other case sample was a bunionectomy with a
distal 1st
metatarsal osteotomy and a proximal hallux
phalanx osteotomy. So, officially, beginning
January 1, 2002, CPT 28299 meets the definition
of what you described as having been performed.

Before you begin appealing the "bundling" -
assuming it was for a surgery prior to 2002 -
you may want to make sure that you were paid
less for CPT 28299 than you would have been paid
billing both CPT 28296 and CPT 28310-59. You may
find that you were paid more or equal to those
codes with CPT 28299. If there is a significant
reduction in reimbursement, I would recommend,
again for cases performed prior to January 1,
2002, making the points on
appeal that

1) You need to see the payer's written guideline
or written reference on the particular coding
2) You are billing exactly what you performed,
and without guidelines or references reflecting
a recognized entity's definition of the coding
combination you would be expected to be
reimbursed for the work done;
3) The value of the work you performed, whether
or not the payer bundled into CPT 28299, should
be equal to the value of CPT 28296 and 50% of
the value of CPT 28310.

The appeal letter should be written
straightforward without emotion. Good luck.

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

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