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Part 2: Strengthen your ICD-10-PCS coding for lumbar spinal fusion procedures. Coding spinal fusion in an outpatient or ambulatory surgery center (ASC) setting with CPT® is very different than coding spinal fusion in the inpatient setting with ICD-10-PCS. For example, as illustrated in Figure 1, CPT® divides the spine into three columns: Anterior (anterior two-thirds […]
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POSTPROCEDURE DIAGNOSTIC IMPRESSION:
1. Severe hallux valgus, left.
2. Dislocation of the second and third metatarsophalangeal joint, left.
3. Hammertoe deformity second and third digit, left foot.
OPERATIVE PROCEDURE:
1. Fusion of first MTPJ right with autogenous bone graft.
2. Metatarsal head resection second and third, left.
3. Arthroplasty PIPJ second and third, left.
DESCRIPTION OF PROCEDURE: The patient was brought to the OR, placed in the supine position, and made to feel comfortable. After administration of IV sedation, 30 cc of 0.5% Marcaine plain was administered via first ray, second ray, and third ray block to the left foot. The foot was then prepped and draped using sterile technique. An Esmarch bandage was used to exsanguinate all blood from the left foot and ankle. The pneumatic ankle tourniquet was elevated to 250 mmHg. Attention was then directed to the dorsomedial aspect of the first MTPJ, where a 6-cm linear incision was performed extending from the midshaft of the first metatarsal to the midshaft of the proximal phalanx. Sharp and blunt dissection was taken through the subcutaneous tissue being careful to avoid all vital structures and bovied all bleeders. Once at the level of the capsule and periosteum, a linear incision was performed extending the length of the skin incision. Sharp dissection was then used to reflect the capsule and periosteum from the head, neck, and distal shaft of the first metatarsal and the base of the proximal shaft of the proximal phalanx. Exposure of the joint revealed erosions of the articular cartilage with significant increase in the PASA – it was deemed appropriate for a fusion. Arthrex cannulated reamers were used to remove the remaining articular cartilage and subchondral bone at the head of the first metatarsal with some osteoporosis noted at the base of the proximal phalanx. While reaming the base of the proximal phalanx, approximately 40% of the superior portion of the base of proximal phalanx was destroyed either to the bone being too soft or the reamer not being adequately sharpened. After careful inspection, the surgical site was irrigated with copious amounts of sterile saline. The hallux was placed in slight abduction and dorsiflexion and a 3-0 guide pin was inserted in the plantar aspect of the remaining base of proximal phalanx extending
from distal medial to proximal lateral. A portion of the medial eminence approximately 3-mm portion of bone graft was also removed and fashioned to fit the defect – this was performed after a small resection of the medial eminence was performed. More bone graft was necessary so attention was directed to the second and third metatarsals, where a linear incision was performed at the lateral and dorsal aspect of the second MTPJ extending from the midshaft of the metatarsal to the base of proximal phalanx. Sharp and blunt dissection was taken down to each MTPJ level being careful to avoid all vital structures and bovied all bleeders. Once at the level of the capsule, a linear incision was performed extending the length of the skin incision – second MTPJ was dissected first and the third and second. Once exposure of the joint was revealed, it was noted to be arthritic at the head of the second metatarsal and inspection of the plantar plate revealed no significant remaining plantar plate for reattachment – it was deemed appropriate for metatarsal head resection, which was performed at approximately the neck level of the second metatarsal. The head was removed in toto and preserved for bone graft. A bone rasp was used to smooth off any remaining bone irregularities. A similar procedure was performed at the third metatarsal head trying to maintain the normal metatarsal parabola. The second metatarsal head was fashioned into an autogenous bone graft with medial and lateral cortical bone intact. After fashioning of all layers of bone graft, they were placed in an appropriate fashion with good bone to bone contact and good filling of the void. A T-plate was then applied along the dorsal aspect of the first MTPJ construct with fashioning of the plate along the dorsal cortex of the head of the first metatarsal and the base of the remaining proximal phalanx. Five screws were placed bicortical with good stability and compression of the fusion site. Surgical site was used to irrigate with copious amounts of sterile saline around the surgical site. A 3-0 Vicryl was used to reapproximate the capsular incision and 4-0 nylon the skin incision. Attention was then directed to the second and third MTPJ levels, where a bone rasp was used to smooth off any remaining bone irregularities. Attention was then directed to the second and third PIPJ level, where a 1.5-cm linear incision was performed with the similar procedure performed on each digit – sharp and blunt dissection was taken through the subcutaneous tissue being careful to avoid all vital structures and bovied all bleeders. Once at the level of the capsule, a transverse incision was used to enter the joint, the medial and lateral collateral ligaments were transected and the extensor tendon apparatus was freed from the head of the proximal phalanx. A bone cutter was used to remove the head of the proximal phalanx at the level of the anatomical neck. A bone rasp was then used to smooth off any remaining bone irregularities. A 0.045-inch K-wire was then inserted through the middle and distal phalanges and retrograded into base of proximal phalanx. The toe was placed in appropriate position and the K-wire was driven into the corresponding metatarsal shaft. Forefoot loading revealed good reduction of deformities. Kwires were bent, cut, and capped. A 3-0 Vicryl was used to reapproximate the MTPJ incision and 4-0 Vicryl the PIPJ incision. A 4-0 nylon was then used to reapproximate the skin incisions. An 8 mg of dexamethasone phosphate was administered evenly around the surgical sites followed by Xeroform and sterile compressive dressing.
PART ONE PROCEDURE PERFORMED:
1. Placement of Pivox PEEK cage (large) 12 mm tall, 16 deg at L5-S1 packed with Bio4 allogenic bone graft.
2. Placement on a large Medtronic Pivox titanium plate fixed with 25.0 mm and 25.0 mm Screws through plate over S1 and L5 bodies anteriorly
3. Placement of Pivox PEEK cage 8 mm tall x 55 mm wide, 6 deg into L34 packed with Bio4 allogenic bone graft.
4. Placement of Clydesdale PEEK cage 10 mm tall x 50 mm wide, 6 deg into L45 packed with Bio4 allogenic bone graft.
4. Total discectomy done anterior/obliquely at L3-L4, L4-L5 and L5-S1.
PART TWO PROCEDURE PERFORMED:
1. Posterolateral fusion performed, L3-4, L4-L5 and L5-S1 with placement of Bio4 allogenic bone graft at L3-L4, L4-L5 and L5-S1 facet joint complex.
2. Placement of Medtronic; Voyager system pedicle screws at the bilateral L3, L4 vertebral bodies of size 6.5 x 50 mm and placement of pedicle screws at the bilateral
S1 verterbal body of size 6.5 x 45 mm.
3. Attachment of 100 mm and 100 mm cobalt chrome rods on the left and right saddles of those pedicle screws, respectively.
4. Placement of temporary navigation reference frame in the left lateral iliac crest.
5. Intraoperative scan for O-arm navigation.
6. Intraoperative neuromonitoring
INDICATIONS:
XXXX is a XX y.o. male who I have been following in the office, who had had complaints of leg pain as well as back pain. he has tried nonoperative treatment including physical therapy
as well as a history of injections. Unfortunately, his relief of symptoms was not sustained with these conservative measures. As a result, imaging studies were reviewed. These showed
significant spondylosis at and degenerative disc disease at L3-L4, L4-L5 and L5-S1 with neuroforaminal stenosis at at each. he was given the option of nonoperative care and we discussed the implications
of a fusion. It was reiterated as well, that discogenic pain is difficult to diagnose. As a result of his condition, I gave him the opportunity to proceed with operative treatment of this condition. In no
uncertain terms have I indicated to the patient that this procedure would cure him of his symptoms. He signed a consent to proceed with surgery.
DETAILS OF PROCEDURE:
After informed consent was obtained, the patient was taken back to the operating room. he was placed under general endotracheal anesthesia. he was then placed in the left lateral decubitus
position with the left side up. The patient was then appropriately secured with tape. All bony prominences were well padded. A time-out was then facilitated in order to ensure this was the
correct patient, and that he was in the correct position, and the correct procedure was to be done. Then, his abdominopelvic region as well as his lumbosacral region were prepped and draped in
the usual sterile fashion. I and my assistant were gowned and gloved in the usual sterile fashion.
I began by initially placing a navigation reference frame in the left lateral and superior iliac crest. An intraoperative scan was then performed utilizing O-arm navigation system. After this scan was
performed, this allowed me and my co-surgeon to localize where the initial oblique incision was to be performed for an interbody fusions. Co-Surgeon, Dr. XXX, performed the oblique approach at L5-S1 and also exposed L4-L5 and L3-L4. He made a 6.5 cm incision with the use of 15-blade knife. I carried this incision through the various muscle plane while splitting them in an atraumatic fashion. We dissected in line through the abdominal muscles, and then identified the peritoneum and went through a retroperitoneal space. We identified and could see the lateral aspect of the lumbar disk spaces. The psoas muscle was lateral and was well protected at L3-L4, L4-L5, but at L5-S1 we approached between the bifurcation of the major vessels. After I identified this appropriate trajectory to the L5-S1 disk space and pinned and placed retractors at this level in order to protect the surrounding tissue, as standard discectomy was performed.
In the posterior space, I made an incision in line with the L3-L4, L4-L5 and L5-S1 lamina and facet joint complex. I sequentially dilated to an 18 mm Medtronic METRx tube system and, utilizing loupe
magnification, identified the lamina as well as the facet joint complex. I introduced a total of about 1.5 cc of Bio4 allogenic bone graft in total at both levels in order to attempt a posterolateral
fusion on this left side. With the posterolateral fusion having been completed, I then turned my attention to placement of the pedicle screws.
I made small stab incisions through the skin and the fascia and dilated to an appropriate size tube, and then introduced a 5.5 mm tap in and through the pedicle and into the vertebral body bilaterally
at L3, L4 and S1. Having completed the tapping for the screw, I then introduced the Medtronic 6.5 x 50 mm Voyager screws into bilaterally L4, L3 and 6.5 x 45 mm screws screws into bilaterally at the
S1 vertebral bodies. With those screws appropriately seated, I then turned my attention back to the anterior interbody approach.
We made an annulotomy through the disk space at L3-L4, L4-L5 and L5-S1. I then completed my diskectomy at those levels by removing the disk material in its entirety at each level. We then tried various size trial implants and settled on the placement of the following at each level.
1. Placement of Pivox PEEK cage (large) 12 mm tall, 16 deg at L5-S1 packed with Bio4 allogenic bone graft.
2. Placement on a large Medtronic Pivox titanium plate fixed with 25.0 mm and 25.0 mm Screws through plate over S1 and L5 bodies anteriorly
3. Placement of Pivox PEEK cage 8 mm tall x 55 mm wide, 6 deg into L34 packed with Bio4 allogenic bone graft.
4. Placement of Clydesdale PEEK cage 10 mm tall x 50 mm wide, 6 deg into L45 packed with Bio4 allogenic bone graft.
As each cage was deployed, this was done with the use of loupe magnification. With the cage in place, a little bit of Floseal was used to control any and all bleeding as well as a Surgicel. I removed all the
retractors. Prior to final closure, a final intraoperative o-arm scan was done confirming correct placement of all hardware. We determined that a 100 mm cobalt chrome rod and a 100 mm rod would be appropriately seated into the saddles of the pedicle screws on the left, and on the right respectively. This was introduced utilizing the voyager delivery system. With that rod deployed into the saddles of the pedicle screws, the rods were final tightened with the appropriate set screw. The towers of those pedicle screws were then removed.
I closed this oblique anterior abdominal wound initially with 2 Vicryl to reapproximate the fascia, 3-0 Vicryl to reapproximate the deep tissue, and then a running 4-0 Vicryl stitch. Steri-Strips were then applied and sterile Medipore dressing. I then turned my attention back to the posterior aspect. All incisions were then thoroughly irrigated. I did place approximately 20 cc of Exparel which had been diluted with 30 cc of normal saline in and around the musculature in the incisions. Closure was performed of the posterior incisions by initially closing the deep tissue with 3-0 Vicryl and reapproximating the skin and closing the skin with 4-0 running Vicryl stitch. Steri-Strips were also applied to these incisions as well and sterile Medipore dressing. The temporary navigation marker was also removed, and this was closed appropriately and sealed with a Medipore dressing.
He was then extubated in the operating in stable condition. All neuromonitoring returned back to baseline. he was transferred to the PACU in stable condition. At the end of the case, needle counts and
sponge counts were correct x2.
I have found three threads on here relating to this, but for the most part they are regarding fusion of the 1st metatarsal cuneiform joint with the bunion repair, which I understand is indeed included in the bunion repair.
I have read a few reports on how tarsometatarsal joint fusion can indeed be billed separately if it is for a separate issue. (hypermobile joint, arthritis) But, they are not from a reputable site. And I have also seen someone quote modifier 59 as stating that a separate diagnosis is not appropriate use of modifier 59.
Is there any documentation out there that specifically states that you cannot bill fusion of the TMT joint (28740) with 28292 and not just fusion of the 1st metatarsal cuneiform?
My providers strongly feel that this is the case, that TMT is separate.
Thank you,
Kelly Lilly