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02/22/2006    Michael McCormick, DPM

CPT 28293 & Hallux Rigidus

Query: CPT 28293 & Hallux Rigidus


My HCA surgery center and their coding company
has consulted with 3M
and Precyse (coding and billing), as well as the
AMA regarding the
use of the CPT 28293 (correction, hallux valgus
[bunion], with or
without sesamoidectomy; resection of joint with
implant) code.


In effect, AMA has indicated that CPT 28293 is
inappropriate to use
unless the diagnosis specifically has
the "Hallux valgus or bunion"
phrase, and that unlisted procedure code, CPT
28899, should be used
for implant arthroplasty of the 1st MPJ for
other diagnoses such as
hallux limitus, hallux rigidus, or hallux varus.


This is contrary to my twenty years experience
with the use of this
code. A certain number of these deformities
certainly have a valgus
component, but many do not.


I am wondering what other people's opinion is on
this. What would be
the ultimate resource to refer the administrator
to?


Michael McCormick, DPM , Venice, FL


Response: This would be a good time to request a
copy of the written
responses received from the AMA, 3M and Precyse
from your ASC's
billing company. It's not that I have reason not
to trust the
billing company, but getting a copy in writing
is always best. The
one I am most interested in is the AMA's
response since I am curious
as to what the AMA's original intent was when
CPT 28293 was
introduced if not to primarily treat conditions
of 1st metatarsal-
phalangeal degenerative joint disease with joint
resection and a
prosthesis as an alternative to joint fusion.


While I appreciate that CPT offers a poorly
worded definition to CPT
28293, to bill CPT 28293 there MUST be a "hallux
valgus (bunion)"
correction performed along with the resecting
the joint "with
implant." Having said that, I have rarely not
found there to be some
periarticular excess bone formation present
(e.g., bulge, lipping,
or prominence of bone) at the proximal phalanx
base and/or 1st
metatarsal head in cases of hallux rigidus. And,
that in the course
of preparing the site for the implant, the 1st
metatarsal-phalangeal
joint is remodeled with all the excess bone
resected - medial,
dorsal, and lateral. I would think that this
sufficiently meets
the "bunion correction" requirement.


The wording, "hallux valgus (bunion)" sets up,
in my mind,
an "either/or" condition for meeting CPT 28293
definitional
requirements. Since a hallux valgus deformity
and a bunion deformity
are two separate entities, correcting either/or
qualifies the code
(assuming you also resect the joint "with
implant" -- I would think
it should read "resecting the joint followed by
implant insertion"
to be clearer).


If you do correct a first metatarsal-phalangeal
joint bony
overgrowth, prominence, bone budge, "bunion"
and/or lipping present;
or if you correct a valgus rotation present in
the great toe, as
well as resect the joint and insert an implant,
you have met CPT
28293 definition.


If you have NO first metatarsal-phalangeal joint
bony overgrowth,
bone prominence, bone budge, and/or bony lipping
present (so
obviously you can't correct it), and you have NO
valgus rotation of
the great toe present (so obviously you can't
correct it), and all
you do is perform a resection of the joint
followed by insertion an
implant, it would not meet CPT 28293 definition,
and you should bill
the unlisted foot procedure code, CPT 28899.


Harry Goldsmith, DPM , Cerritos, CA


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