Coding for Bunionectomy, a Common Foot and Bone Surgical Procedure

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If you happen to experience a bulging bump on the outside of the base of your big toe, then it must be a symptom of a bunion. A bunion is a foot deformity that consists of both bone and soft tissue. Also known as “Hallux Valgus,” bunions occur when the bone of the big toe excessively angles or pushes against the next toe (instead of straight ahead), forcing the joints to get bigger and protrude. In due course, the normal structure of the bone changes, resulting in a bony bump and the skin over the bunion may turn red and become sore. In certain cases, the foot condition may also occur at the base of the little toe instead of the big toe – known as bunionettes or “tailor’s bunion.” If left untreated, this bone condition can gradually increase and make it extremely painful for the person to wear shoes and interfere with walking and exercising. Treatment options for this bone condition vary depending on the severity of the bunion and the amount of pain it causes. In some mild cases, the condition can be affectively managed by making key lifestyle adaptations (like choosing appropriate fitting footwear, shoe inserts/orthotics) and using pain medications and cortisone injections. If conservative measures fail and patients still experience pain that interferes with their daily activities, surgical intervention known as “Bunionectomy” may be done to excise, or remove a bunion. Podiatrists or other physicians who perform this surgical procedure need to correctly document the same in the patient’s medical records. Opting for podiatry medical billing services from an established medical billing company can help simplify the documentation process.

Any person can get a bunion, but this condition tends to be more common among women. It is most often caused by wearing tight, narrow shoes that squeeze the toes together. In addition, factors such as an inherited structural defect, placing additional stress on the foot over a prolonged period or a medical condition like arthritis can also cause the condition. In most cases, bunion pain is relieved by wearing wider shoes with adequate toe room and using other simple treatments to reduce pressure on the big toe.

What Is Bunion Removal?

Bunion removal is a surgical procedure that corrects a deformed area of the foot near the big toe. Bunion removal is also called a bunionectomy, bunion surgery, or hallux valgus correction. Generally, the common goals of bunion surgeries include – realigning the metatarsophalangeal (MTP) joint at the base of the big toe, relieving pain and correcting the deformity of the bones making up the toe and foot.

Types of Bunionectomy

As bunions vary in shape and size, there are different surgical procedures performed to correct them. In most cases, these surgical procedures include correcting the alignment of the bone and repairing the soft tissues around the big toe. The type of surgical procedure performed depends on several factors like – severity of the bunion, patient age, general health, activity level, and the condition of the bones and connective tissues. Types of bunionectomy include –

  • Repairing tendons and ligaments – If tight or loose soft tissues are causing the bunion to form, the surgeon may loosen tight tendons and ligaments or tighten loose ones. This procedure is generally performed in addition to others.
  • Osteotomy – In this procedure, the surgeon will cut the big toe joint and realign it to a normal position. Osteotomies may be performed in different places along the bone to correct the deformity. In some cases, in addition to cutting the bone, a small wedge of bone is removed to provide enough correction to straighten the toe.
  • Exostectomy – Typically, exostectomy is performed in conjunction with other types of surgery, such as soft tissue removal and an osteotomy. Exostectomy involves removing the bony bump from the big toe without performing an alignment. However, the bunion deformity often returns if a physician performs exostectomy without osteotomy.
  • Arthrodesis – Arthrodesis is commonly performed for patients who have severe bunions or severe arthritis, and for patients who have had previous unsuccessful bunion surgery. In this procedure, the podiatric surgeon will remove the areas of arthritic joints (before using plates, screws, or wires) to hold the surfaces together until the bones heal.
  • Resection arthroplasty – This procedure is typically recommended for elderly people with arthritis (that an arthrodesis may not treat) and who have had previous unsuccessful bunion surgery. The surgeon removes the damaged portion of the joint to provide more space between the bones.

How Is Bunionectomy Performed?

Bunionectomy is generally performed on an outpatient basis and procedures may vary depending on the patient’s condition. Most cases of bunion surgeries are performed under ankle block anesthesia, (where in the patients foot is numb, but they are awake). Occasionally, general or spinal anesthesia is used. Before undergoing the procedure, physicians may conduct tests such as – electrocardiogram, cardiogram, chest X-ray and urine and blood tests to detect any illness or infection. The surgeon will cut, realign, and possibly remove portions of bone, ligaments, and tendons of the affected foot based upon the severity of the bunion. The time required for the surgery may depend on how much the foot is misaligned. Surgery will take longer if the deformity is greater or if more than one osteotomy is required.

Bunionectomy – Coverage Criteria and Coding Guidelines

Bunionectomy (Hallux valgus surgery) is considered medically necessary when there is a confirmed diagnosis of hallux valgus and any of the following signs/symptoms is directly attributable to a hallux valgus deformity –

  • Difficulty walking
  • Significant and persistent pain at first metatarsophalangeal joint (which interferes with necessary physical activity)
  • Ulceration at the first metatarsophalangeal joint

Other additional criteria include –

  • If the signs/symptoms are unresponsive to the use of appropriate foot wear and at least six months of conservative treatment, including at least two of the following –
    • Padding
    • Oral analgesics or anti-inflammatory medications
    • Local injections to the first metatarsophalangeal joint (i.e., local anesthetic or steroid)
  • Ulceration at the first metatarsophalangeal joint that has not responded to four weeks of local wound care.

Podiatry coding and billing can be challenging as it involves using several code categories. Podiatric surgeons or other specialists who perform bunionectomy must use the relevant medical codes to document the diagnosis, screening and other procedures performed. Medical coding services offered by reputable companies can help physicians use the correct codes for their medical billing process.

Before selecting a code for bunionectomy procedure, it is important to know the type of procedure performed and to verify its components. According to the American Medical Association’s (AMA) CPT® Assistant, all hallux valgus (bunionectomy) procedures include:

  • Removal of the bony prominence (bunion)
  • Removal of additional osteophytes
  • Arthrotomy
  • Capsulotomy
  • Tenotomy
  • Tendon releases
  • Tenolysis
  • Placement of internal fixation
  • Removal of bursal tissue
  • Articular shaving at the first metatarsophalangeal joint

Medical Codes for Bunionectomy

ICD-10 Codes

  • M20.1 – Hallux valgus (acquired)
    • M20.10 – Hallux valgus (acquired), unspecified foot
    • M20.11 – Hallux valgus (acquired), right foot
    • M20.12 – Hallux valgus (acquired), left foot

CPT Codes

  • 28292 – Correction, hallux valgus (bunionectomy), with sesamoidectomy, when performed; with resection of proximal phalanx base, when performed, any method(CPT code 28292 – describes the correction of a hallux valgus deformity, and includes sesamoid bone removal or a proximal phalanx base resection, when necessary. The sesamoid bone removal, or removal of part of the articulating end of the bone (closest to where it attaches), realigns the toe with the metatarsal at the metatarsophalangeal joint. This is generally done for mild deformities where there is very little deviation of the metatarsal)
  • 28295 – Correction, hallux valgus (bunionectomy), with sesamoidectomy, when performed; with proximal metatarsal osteotomy, any method
  • 28296 – Correction, hallux valgus (bunionectomy), with sesamoidectomy, when performed; with distal metatarsal osteotomy, any method(CPT code 28296 was revised to add the word “distal,” which describes the location of the metatarsal osteotomy. Use code 28296 to correct a hallux valgus deformity with a distal metatarsal osteotomy. The procedure may also include sesamoid bone removal, when necessary, to help with bone realignment. This type of correction is done for patients with mild hallux valgus of less than 40 degrees and a minimal increase in the deviation of the metatarsal).
  • 28297 – Correction, hallux valgus (bunionectomy), with sesamoidectomy, when performed; with first metatarsal and medial cuneiform joint arthrodesis, any method(CPT code – 28297 reports a bunion correction with a joint fusion between the foot bone located behind the big toe (first metatarsal) and the bone of the middle foot located behind the first metatarsal. The fusion may be done with sesamoid bone removal, when necessary. This type of bone correction is specifically done for a severe intermetatarsal angle or instability of the first tarsometatarsal joint.)
  • 28298 – Correction, hallux valgus (bunionectomy), with sesamoidectomy, when performed; with proximal phalanx osteotomy, any method(CPT code – 28298 reports a bunion correction that includes a proximal phalanx osteotomy where bone is removed at the base of the big toe. This surgical procedure may be performed with sesamoid bone removal, when necessary, to help with bone realignment.)
  • 28299 – Correction, hallux valgus (bunionectomy), with sesamoidectomy, when performed; with double osteotomy, any method(CPT code 28299 reports a bunion correction where two osteotomy procedures are done to straighten the toe and the metatarsal. These corrections may be done along with sesamoid bone removal, (when necessary), to help with realignment. The double osteotomy combines an osteotomy of the phalanx and the metatarsal (proximal or distal) or a proximal and distal metatarsal osteotomy).
  • 28899 – Unlisted procedure, foot or toes
    The surgery time varies depending on how much of the foot is damaged. The surgery will take a longer time if the deformity is greater or if more than one osteotomy is required. After the completion of the surgery, patients will be shifted to a recovery room. While initial recovery after bunionectomy may normally take about 6-8 weeks, full recovery can take an average of four to six months.

For the first two weeks after undergoing surgery, patients will need to wear a surgical boot or cast to protect their foot. After removing the cast or boot, patients need to wear a brace to support their foot while healing takes place. Patients need to make sure that they don’t bear weight on their foot at first, and they can use crutches for assistance. Gradually, they can start putting some weight on the foot, using a walker or crutches for support. Icing the foot and toe helps to speed up healing and reduce inflammation. Patients before undergoing bunionectomy need to discuss with their podiatrists about the possible measures that they need to take to ensure correct healing of their foot.

Knowing the highly specific medical codes related to bunionectomy procedure is critical for podiatrists. Partnering with an experienced medical billing and coding company is a great option for podiatrists to ensure accurate and timely claim submissions.

Natalie Tornese

Holding a CPC certification from the American Academy of Professional Coders (AAPC), Natalie is a seasoned professional actively managing medical billing, medical coding, verification, and authorization services at OSI.

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