A patient with hallux abductor valgus of the right foot presents for repair of the deformity. The surgeon performs two procedures to correct this deformity, a “modified” McBride bunionectomy and an opening base wedge osteotomy with bone graft of the first right metatarsal. According to the operative report the opening base wedge osteotomy was performed through a separate incision over the first metatarsal. How should these procedures be reported?
It would be appropriate to report CPT code 28292, Correction, hallux valgus (bunion), without sesamoidectomy; Keller, McBride, or Mayo type procedure, to describe the Modified McBride Bunionectomy performed.
Since the osteotomy with bone graft was performed through a separate incision, CPT code 28307, Osteotomy, with or without lengthening, shortening or angular correction, metatarsal; first metatarsal with autograft (other than first toe) should be reported. Append modifier RT, Right, to identify that the procedure was performed on the right foot. In addition, modifier 59 would also be appended to the second CPT code.
A patient presents with a wound to the fifth metatarsal head of the right foot. Irrigation and sharp debridement were performed. The debridement was extended into some of the joint capsule. Would CPT code 11043 be the appropriate code to report for this procedure?
It would be inappropriate to assign an additional code for injections performed during CPR. The injection would be considered inherent to the CPR service and would not be separately reported.
According to guidance provided by CMS for hospitals under the OPPS, hospitals now have the option to report multiple HCPCS codes for a single drug administered, or continue to bill the HCPCS code with the lowest dosage descriptor available. Therefore, your reporting options are:
- 1 unit of HCPCS code J1040, Injection, methylprednisolone acetate, 80mg, and 1 unit of HCPCS code J1030, Injection, methylprednisolone acetate, 40mg, Or
- 3 units of HCPCS code J1020, Injection, methylprednisolone acetate, 20mg, for the injection of 120mg of Depomedrol, Or
- 6 units of HCPCS code J1020, Injection, methylprednisolone acetate, 20mg, for the injection of 120mg of Depomedrol.
Report CPT code 20610, Arthrocentesis, aspiration and/or injection; major joint or bursa (eg, shoulder, hip, knee joint, subacromial bursa), for the injection procedure performed with modifiers RT, Right, and LT, Left, where appropriate.