Hospital Outpatient Surgery Services

The following documentation is from the health record of a 68-year-old male patient.

Hospital Outpatient Surgery Services

This patient presented to the podiatrist for surgical evaluation at the request of the primary care physician. After surgery was completed, a copy of the evaluation and operative report was sent to the primary care office.

Preoperative Evaluation: This 68-year-old male of Italian descent presents with degenerative arthritis and bunion formation. On 6/30/XX, patient was sent by Dr. Brown for bunionectomy evaluation. A problem-focused history was conducted followed by an expanded problem-focused examination.

Impression: Painful left foot due to: (1) Bunion with primary localized degenerative joint disease in the toes. (2) Metatarsus primus varus. (3) Hammer toe, second digit. (4) Elongated metatarsal, second digit, left.

Plan: Surgery scheduled for 8:00 a.m. 7/12/XX, at the Hospital

Procedures: Keller bunionectomy; Austin bunionectomy; arthroplasty, second digit; and excision of the metatarsal head, second digit, left foot

Operative Report: The patient was placed in the semisupine position where Dr. Graybeard administered spinal anesthesia. After prepping and draping the patient in the usual aseptic manner and under ankle hemostasis, the left foot was approached. A dorsal linear incision was performed medial to the extensor hallucis longus tendon. Incision was carried through the skin and subcutaneous tissue and extended from midshaft metatarsal to distal proximal phalanx. The superficial fascia was separated from the deep fascia using sharp and blunt dissection techniques. An inverted L-capsulotomy was performed and sharp capsular periosteal dissection was performed with a #15 blade to expose the first metatarsal and base of the proximal phalanx. The medial eminence was resected with a micro-oscillating saw.

Next, attention was directed to the base of the proximal phalanx, where the Keller procedure was performed. One-third of the proximal phalanx was resected and excised in toto.

Attention was next directed to the head of the first metatarsal where an Austin osteotomy was performed in the usual manner with screw fixation. The area was flushed with copious amounts of antibiotic flush. The capsular periosteal layer was next closed with 3-0 VICRYL. The subcutaneous tissue was reapproximated with 4-0 VICRYL.

Attention was next directed to the second digit and MPJ area, where a dorsal curvilinear incision was performed. The incision was deepened and the PIPJ was exposed. A transverse incision was performed through the capsular periosteal tissue at the PIPJ. Medial and lateral capsulotomies were performed, exposing the head of the proximal phalanx. The head of the proximal phalanx was resected and excised in toto.

Attention was next directed to the second MPJ. The incision at this area was deepened. A dorsal linear capsulotomy was performed and the head of the second metatarsal was resected and excised in toto. The surgical sites were next flushed with copious amounts of antibiotic flush. The second digit was noted to be aligned without pressure on the neurovascular structures.

Next, a .45 K-wire was placed percutaneously into the hallux distal to proximal. Capsular periosteal closure was next performed with 3-0 VICRYL. Subcutaneous closure was performed with 4-0 VICRYL. The skin was closed in 4-0 nylon. Postop anesthesia consisted of 17 cc 5.0 percent Marcaine plain and 1 cc of Decadron 4 mg/ml. Next, the sterile dressing was applied, which consisted of Betadine ointment, 4 x 4 gauze, and 4-inch Kling. The tourniquet was released, and the patient was returned to recovery in stable condition.

Which of the following is the correct ICD-10-CM and CPT code assignment for this outpatient procedure?

A. M20.12, M20.42, 99242-25, 28202, 28285

B. M20.12, Q66.21, 28296

C. M20.12, M19.072, Q66.21, M20.42, 28296-TA

D. M20.12, M19.072, Q66.21, M20.42, Q66.9, 28299-TA, 28285-T1