04/30/2004    Ted Couluris, DPM

1st MPJ Arthrodesis

Query: 1st MPJ Arthrodesis

I recently performed a 1st metatarsal-phalangeal
joint (MPJ) arthrodesis. The patient had a
dislocated MPJ and varus deformity
after a two-component implant replaced the joint
years ago. The surgery involved removal of both
implant components, and the placement of
allograft material to fill the void. A surgical
plate was utilized for fixation and stability of
the site.

The graft preparation was fairly intensive,
involving 20 minutes of preparation both on the
back table and at the surgical site. I feel
this was obviously more involved than a
straightforward 1st MPJ arthrodesis with cross
screws. Are there another other billing
options other than just CPT 28750 (arthrodesis,
great toe; metatarsophalangeal joint)?

Ted Couluris, DPM
Clearwater, FL

Codingline response: CPT 28750 (arthrodesis,
great toe; metatarsophalangeal joint) is the
most appropriate code for the procedure
described.

The other option open to you is one discussed
multiple times in the past on Codingline: the
use of modifier "-22". This modifier
indicates that the procedure required more than
usual work, time and effort. Also, as has been
discussed, you may want to bill CPT 28750
without the "-22" modifier first, get paid, and
then submit a corrected claim with the "-22"
modifier. Be prepared to send copies of your
operative to substantiate your claim that the
case was more involved.

Craig Gastwirth, DPM
Detroit, MI

Other messages in this thread:

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03/14/2006    Rich Bouche', DPM

Malposition, 1st MPJ Arthrodesis (Stephen Merena, DPM)

RE: Malposition, 1st MPJ Arthrodesis (Stephen
Merena, DPM)
From: Rich Bouche', DPM

I think it is important in 1st MTPJ arthrodesis
procedures for the
hallux to bear weight. I routinely position the
hallux in a parallel
position to the supporting surface. In surgery,
this is accomplished
by loading the foot on an instrument tray with
the foot in neutral
dorsi-flexion and having the hallux lightly
contact the tray.
Frontal plane positioning can be slight valgus
or neutral (no varus)
and the transverse position should be 5-15
degrees of abductus. A
few patients have presented with interphalangeal
joint(IPJ) symptoms
but this usually is due to a rectus or adductus
(varus) postioning
of the hallux ("outrigger effect") in the
transverse plane which is
a problem.

A few patients have also experienced transient
IPJ symptoms that
Resolved over a 1-3 month period of time with
conservative care and
the tincture of time. To confirm an over-plantar-
flexed malposition,
a Harris pressure mat can validate increased
excessive pressure at
the IPJ level. If this is indeed the case and
there are no IPJ
changes radiographically, conservatively I would
attempt a hallux
cut-out (on insole or orthoses) with a rigid
Rocker-soled type shoe-
this should be significantly helpful.

Should symptoms persist despite these simple
measures, then a dorsi-
flexory osteotomy of the base of the proximal
phalanx can be
considered or a crescentic osteotomy at the
arthrodesis site (from
medial to lateral at fusion site) can work
nicely to allow
a "dialing in" of the desired sagittal position.
Interestingly, in a
large number of athletic patients with this
arthrodesis technique
that I describe above, I am aware of only a few
isolated cases of
IPJ problems. For the hallux to successfully
function without
symptoms in this weight-bearing position though,
accurate alignment
in the cardinal planes as mentioned above is
paramount. Would like
to see your patient's x-rays.

Rich Bouche', DPM, Seattle, WA,
spmrtb@earthlink.net