PREOPERATIVE DIAGNOSIS 1. Morton’s neuroma, 3rd interspace, left foot, causing chronic discomfort.
2. Morton’s neuroma, 3rd interspace, right foot, causing chronic discomfort.
POSTOPERATIVE DIAGNOSIS: Same.
PROCEDURE PERFORMED: 1. Excision of Morton’s neuroma, 3rd interspace, left foot, under loupe magnification.
2. Nerve implantation, left foot.
3. Excision of Morton’s neuroma, 3rd interspace, right foot.
4. Nerve implantation, right foot.
ANESTHESIA: Local with intravenous sedation per Dr. Scott Himelstein.
FLUIDS: Crystalloid.
ESTIMATED BLOOD LOSS: 20 mL.
TOURNIQUET: Bilateral ankle pneumatic tourniquets to 250 mmHg.
COMPLICATIONS: None.

INDICATIONS: This 49-year-old female has been followed in my outpatient clinics over the past year with multiple foot complaints. Her main issue has been Morton’s neuromas that have been treated conservatively with cortisone injections, orthotic management, NSAIDs, and attempt at sclerosing agent injections. She did obtain relief for short periods of time with the injections — making the diagnosis definitive, but unfortunately, the injections did not ameliorate her symptoms. She is requesting operative intervention in an attempt to address her underlying structural/functional foot deformities in an attempt to ameliorate her symptoms.

PHYSICAL EXAMINATION: Neurovascular status was grossly intact of the bilateral extremities. Pedal pulses are +2. There is pain with palpation of the 3rd intermetatarsal space with distal and proximal paresthesias, positive Mulder’s. There is no pain at the 2nd or 4th interspace area. No pain at the lesser metatarsophalangeal joint areas bilateral.

CONSENT: The above diagnosis was established and the procedures recommended. The procedure, postoperative care, and possible complications, including but not exclusive to risks of infection, delayed or nonhealing, continued pain at the area, possibility of numbness and/or nerve entrapment and chronic pain syndrome/RSD/CRPS, and stump neuroma formation. Heather relates she accepts the above stated risks and complications and requests the above operative intervention. No medical contraindications were identified to preclude the above surgery.

Prior to the patient being brought into the Operating Room, she was administered 2 grams Ancef for general orthopedic prophylaxis.

OPERATIVE SUMMARY: The patient was brought to the Operating Room and placed on the table in the supine position. Intravenous sedation was administered per Dr. Himelstein. At that point in time, Dr. Miller performed a local field block consisting of 0.5% Marcaine with dexamethasone phosphate in a 9:1 ratio over the proximal surgical sites of the both feet. Both feet and legs were prepped and draped in the usual aseptic manner. Pneumatic ankle tourniquets were placed, and after elevation to 60 degrees for 3 minutes, inflated to 250 mmHg.

1. Excision of Morton’s neuroma, 3rd interspace, left foot, under loupe magnification. Attention was directed to the 3rd intermetatarsal space where approximately 3 cm incision was made and under loupe magnification the procedure was performed. The incision was deepened, vital structures identified and retraced, bleeding vessels cauterized per electrocautery. Both sharp and blunt dissection was carried down to the deep transverse intermetatarsal ligament where it was identified and transected to reveal a large neuromatous mass. The neuromatous mass was identified and traced out distally to its bifurcations to the 3rd and 4th toe where it was transected and the neuromatous mass was then brought back proximal-proximal to the deep transverse intermetatarsal ligament where it was transected while utilizing gentle traction on the nerve. It was transected with a 15-blade without incident. The wound was irrigated with copious amounts of sterile saline and bacitracin solution. The skin was reapproximated with 4-0 nylon in simple horizontal fashion. This completed the excision of Morton neuroma, 3rd interspace.

2. Excision of Morton’s neuroma, 3rd interspace, right foot, under loupe magnification. Attention was directed to the 3rd intermetatarsal space where approximately 3 cm incision was made and under loupe magnification the procedure was performed. The incision was deepened, vital structures identified and retraced, bleeding vessels cauterized per electrocautery. Both sharp and blunt dissection was carried down to the deep transverse intermetatarsal ligament where it was identified and transected to reveal a large neuromatous mass. The neuromatous mass was identified and traced out distally to its bifurcations to the 3rd and 4th toe where it was transected and the neuromatous mass was then brought back proximal-proximal to the deep transverse intermetatarsal ligament where it was transected while utilizing gentle traction on the nerve. It was transected with a 15-blade without incident. The wound was irrigated with copious amounts of sterile saline and bacitracin solution. The skin was reapproximated with 4-0 nylon in simple horizontal fashion. This completed the excision of Morton neuroma, 3rd interspace.

3. Implantation of nerve, left lower extremity. Attention was directed to the 3rd interspace area where an approximately 3 cm incision was made coursing back out to the previous incisional area. The incision was deepened, vital structures identified and retracted, and bleeding vessels cauterized with electrocautery. The procedure was performed under loupe magnification and dissection was carried down to the transected nerve where it was identified and then the nerve was placed within the intrinsic muscular area of the 3rd interspace and sutured with a perineurial technique utilizing 3-0 Vicryl suture to secure the nerve into the implanted area. The wound was irrigated with copious amounts of sterile saline and bacitracin solution. The skin was reapproximated with 4-0 nylon in simple horizontal fashion.

4. Implantation of nerve, right lower extremity. Attention was directed to the 3rd interspace area where an approximately 3 cm incision was made coursing back out to the previous incisional area. The incision was deepened, vital structures identified and retracted, and bleeding vessels cauterized with electrocautery. The procedure was performed under loupe magnification and dissection was carried down to the transected nerve where it was identified and then the nerve was placed within the intrinsic muscular area of the 3rd interspace and sutured with a perineurial technique utilizing 3-0 Vicryl suture to secure the nerve into the implanted area. The wound was irrigated with copious amounts of sterile saline and bacitracin solution. The skin was reapproximated with 4-0 nylon in simple horizontal fashion.

The tourniquet was released and blood flow was reestablished to digits 1, 2, 3, 4, and 5 of both feet and, in particular, all four quadrants of digits 1, 2, 3, 4 and 5 and the surrounding incisional areas. A sterile dressing was applied with surgical shoes. The patient tolerated the procedures and anesthesia well, and was discharged to PAR in stable condition.

HERE IS THS ISSUE IM HAVING………

Due to specific CPT 2018 instructions: "For Morton neurectomy, use 28080"
Excision of Morton’s Neuroma, each, (RT Foot; Lt Foot): 64782×2 should be 28080×2

Due to CPT 2018 instructions for the add-on codes: "Use 64787 in conjunction with 64774-64786"; this does not allow use with 28080.

Implantation of nerve end into bone or muscle for each nerve: 64787×2 should MAYBE be an unlisted code 64999??
I believe Documentation supports the 64787 codes…..

I can’t find definitive instructions about the use of 28080 and 64787 codes that would allow reporting the implantation part of the surgery with the Morton’s neurectomy.

Any help is greatly appreciated.