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ICD-10 Transition tips and tools

Outpatient Surgical Coding Exercise: Hallux Hammertoe Deformity

As you have seen in the past outpatient ICD-10 articles, being ready for the ICD-10-CM coding switch can save hospitals valuable time in getting claims out the door. It is never too early to begin comparing how to assign the ICD-10-CM codes on outpatient encounters to how you assigned them with ICD-9-CM codes.

Case Study

Preoperative Diagnosis:     Hallux hammertoe deformity, right foot

                                                Cavovarus foot type, right foot

Postoperative Diagnosis:    Hallux hammertoe deformity, right foot

                                                Cavovarus foot type, right foot

Procedure:                             Hallux interphalangeal joint fusion, right foot, with extensor hallucis longus tenosuspension

Procedure Description: The patient was brought to the operating room and placed on the table in the supine position. Intravenous access was achieved and patient was sedated. A Mayo block was performed around the first ray using 1% Lidocaine and 0.25% Marcaine plain. The foot was prepped and draped in the usual sterile manner. A sterile ankle tourniquet was applied and infiltrated to 250 mmHg.

Attention was directed to the dorsal aspect of the great toe and first metatarsophalangeal joint where a non-reducible contracture of the great toe was present. Incision was made medial to the long extensor tendon from an area about 4 cm proximal to the first metatarsophalangeal joint, across the first metatarsal joint, and then a lazy-S across the hallux interphalangeal joint was performed. This was deepened via sharp dissection and bleeders were coagulated. Dissection was carried where neurovascular structures were identified and retracted. The hallux interphalangeal was identified, and transverse tenotomy and capsulotomy was performed, exposing the head of the proximal phalanx. Soft tissue was reflected from the head of the proximal phalanx and base of the distal phalanx. A power saw was used to resect subchondral bone and articular cartilage and pieces of bone were removed from each side of the joint. The hallux was held in a rectus position. The distal aspect of the toe was then incised transversely for about 7 mm. This was deepened to the level of bone. A guide pin was then inserted and driven across the interphalangeal joint from the distal aspect of the toe. This position was confirmed on fluoroscopy, and a 48 mm 4.0 cannulated screw was inserted. The joint was found to be very stable and rigid.

Attention was directed to the metatarsophalangeal joint where the patient still showed a significant contracture. The extensor hallucis longus tendon was dissected from the tenotomy area over the hallux interphalangeal joint proximally. A dorsal capsulotomy was performed at the first metatarsophalangeal joint and periosteum reflected over the first metatarsal neck. An Arthrex corkscrew bone anchor was then inserted. The excess tendon was resected, and the extensor hallucis longus tendon was sutured to the neck of the first metatarsal. The surgical sites were then flushed. The toe was in excellent position, showing good range of motion. Subcutaneous tissues were then closed using 3-0 Vicryl suture. The skin was repaired with 3-0 nylon in a simple interrupted fashion. The tourniquet was released and good color was noted to the entire digit. Dressings were applied, and a short leg splint was applied as well. The patient tolerated the procedure well and was transferred to the recovery room.

Codes Assigned
Listed below in the first table is a comparison of the ICD-9 diagnosis codes and the ICD-10 diagnosis codes. As you can see, the descriptors are similar.

ICD-9-CM Diagnosis Codes

ICD-10-CM Diagnosis Codes

735.4     Acquired hammer toe

754.59   Congenital varus deformity of foot

M20.41   Other hammer toe(s) (acquired),               right foot

Q66.1      Congenital talipes calcaneovarus

Note also that each digit of the ICD-10 diagnosis code is a specific identifier:

  • The first code listed (M20.41) can be broken down like this: M = Chapter 13: diseases of the musculoskeletal system and connective tissue; 20-25 = other joint disorders with 20 specifically identifying acquired deformities of fingers and toes; .41 = other hammer toe(s) (acquired), right foot.
  • The second code listed (Q66.1) can be broken down like this: Q = Chapter 17, congenital malformation, deformation and chromosomal abnormalities, with 66 specifically identifying congenital deformities of feet; and .1 equaling congenital talipes calcaneovarus.

Now review the table below, which lists the ICD-9 procedure codes against the ICD-10 procedure codes, and you will see their descriptors differ. However, per HIPAA guidelines, these codes cannot be used for outpatient cases but may be used for inpatient cases. For outpatient cases, use instead CPT code 28760 -- arthrodesis, with extensor hallucis longus transfer to first metatarsal neck, great toe, interphalangeal joint.

ICD-9-CM Procedure Codes


77.58  Other excision, fusion and repair of toes

0SGP04Z   Fusion of toe phalangeal joint, right

Like the ICD-10 diagnosis codes, each digit in the ICD-10-PCS column identifies a specific feature. For the code above, it goes like this: 0 = medical and surgical; S = lower joints; G = fusion; P = toe phalangeal joint, right; 0 = open approach; 4 = internal fixation device; and Z = no qualifier.

Susan Howe is a senior healthcare consultant at Medical Learning Inc. (MedLearn), St. Paul, MN.

ICD 10 Transition tips and tools Archives

If only tenotomies and tendon transfers are done on the flexor tendons and tenotomy of extensor tendons without transfder is done how would you code these?

On T1,T2,T3

jduith keech,  CCS,  MSRMCMarch 29, 2012
Palmer, AK

There should be another procedure in PCS for the tenosuspension of the extensor hallucis longus. Unlike CPT, in PCS there can be two root operations and in this case, there is one for the fusion and one for the tenosuspension which must be represented differently as a root operation in PCS. Our group of coders, Certified ICD-10 Academy Trainers, and content management staff believe that there is a second PCS code needed for this particular example.
Could you please comment on this? Thank-you, Wendy Zumar, MA, RHIA, CCS

Wendy Zumar,  content analystMay 27, 2011
Aurora, CO

TreatmentBunions may be treated conservatively with changes in shoe gear, different orthotics (accommodative padding and shielding), rest, ice, and medications. These sorts of treatments address symptoms more than they correct the actual deformity. Surgery, by an orthopedic surgeon or a podiatrist, may be necessary if discomfort is severe enough or when correction of the deformity is desired.

OrthoticsOrthotics are splints, regulators while conservative measures include various footwear like gelled toe spacers, bunion / toes separators, bunion regulators, bunion splints, and bunion cushions.

Podiatrist Kamran Jamshidinia, DPM performing surgery to remove the bony enlargement & restore normal alignment of the toe joint.Procedures are designed and chosen to correct a variety of pathologies that may be associated with the bunion. For instance, procedures may address some combination of:

removing the abnormal bony enlargement of the first metatarsal,
realigning the first metatarsal bone relative to the adjacent metatarsal bone,
straightening the great toe relative to the first metatarsal and adjacent toes,
realigning the cartilagenous surfaces of the great toe joint,
addressing arthritic changes associated with the great toe joint,
repositioning the sesamoid bones beneath the first metatarsal bone,
shortening, lengthening, raising, or lowering the first metatarsal bone, and
correcting any abnormal bowing or misalignment within the great toe.
At present there are many different bunion surgeries for different effects. Ultimately, surgery should always have function of the foot in mind besides its look. Can the proposed surgery help resolve the pain and callus under the middle metatarsal heads? Can one return to sports? Can the foot enjoy fashionable or high heel shoes like normal feet without undue discomfort? Does the proposed surgery prevent recurrence with any specific built-in mechanism? These are very reasonable challenges for any truly functional bunion surgeries but may not be so for esthetic bunion surgeries.

The age, health, lifestyle, and activity level of the patient may also play a role in the choice of procedure.

Bunion surgery can be performed under local, spinal, or general anesthetic. The trend has moved strongly toward using the less invasive local anesthesia over the years. A patient can expect a 6- to 8-week recovery period during which crutches are usually required for aid in mobility. An orthopedic cast is much less common today as newer, more stable procedures and better forms of fixation (stabilizing the bone with screws and other hardware) are used.

James BakerApril 01, 2011
Philadelphia, PA

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