Hello, on behalf of AOFAS, I want to welcome you to the 6th session of the Crack the Codes Practice Management and Coding Series. Today's session is Common Surgical Procedures for Foot and Ankle. Today's presentations will be given by Jennifer Cabrera and Jennifer Bell. You can find their full biographies and disclosures in the program document posted in the On Demand Education Center. This series is funded from the Orthopedics Foot and Ankle Foundation, supported in part by a grant from Paragon 28. I'd like to run through a few housekeeping items before we kick off the presentation. For technical difficulties, please try closing your browser and logging back in the same way you did the first time. Registered physician attendees may earn one hour of AMA, PRA, Category 1 CME credit for this session by completing an evaluation and CME claim form at the end of the full series. Tomorrow, you will receive an email with a link to evaluate the specific session, and then at the end of the sub and broadcast, you will be able to evaluate and claim CME for the full course. This webinar is being recorded and will be available for on-demand viewing in the On Demand Education Center as a module within this course listing in approximately 24 hours. The recording will be available for one year. We encourage you to ask questions during the presentation. To send your question to the faculty, click on the Q&A tab on your navigation bar. If we cannot get to your question during the live broadcast, the faculty will reach out to you following to respond. I will now turn the program over. Thank you. All right. Good morning, everybody. Thank you for joining us today for a presentation on common surgical procedures for foot and ankle. Just so you're aware, this is Karen Zupko, an associate. This is who Jen and I both work with. Karen's been around for about 37 years and worked in all aspects of health care, including billing, coding, practice management, consulting. This is our co-presenter here, the wonderful Jennifer Bell. And I am Jennifer Cabrera. I'll be taking you through these topics for the next hour. Thank you again for joining us. Just a brief little overview today. Obviously, we're doing a lot of coding and surgical questions and whatnot. So feel free to put in those Q&A's into your Q&A section so we can get those questions answered. There will be time at the end to review some of those things as well. And then in addition, I know we do have some coders on here. So welcome. We are very happy to have you. And thank you so much for being here, guys. Let's get started. All right. So just as we get started, just a little brief overview of anatomy and terminology for foot and ankle. Remember, the key with any documentation for physician, billing, coding is it all comes down to the documentation. So making sure you really keep track of that anatomy. Obviously, there's lots of bones, ligaments, tendons, everything going on in the foot and ankle. And we want to make sure that we're very clear and that it's clearly stated in your notes where you're working, as a lot of these codes are dependent on location. So just making sure you're very clear with that. In your workbook, you do have a slide, excuse me, a page in your workbook that goes over a lot of the key ICD-10 codes for foot and ankle. I don't have a slide on that here, but it is in your workbook. Just reviewing with you the most common that we see, obviously. And just of note of that, remember, you've got your sprains and strains, laceration codes, and then you've got your more frequently used musculoskeletal conditions, such as pes planus or Tarsal Tunnel Syndrome and whatnot. So just make sure you're being very specific with your coding on your ICD-10. In addition, remember, the most common sprain that we see in the ankle is of the ATFL or anterior talofabular ligament. Remember, that's the most common injury site, but there is not a specific code for the ATFL. So make sure you're using that sprain of other ligament code, RS-93, and it's right for 0.491, 0.492 for left, and then you've got your unspecified. So we don't have that ATFL code, so we use the sprain of other ligament in the ankle. All right, so now we're going to talk just a little bit about arthrodesis here. So you can see in your workbook and on this slide here, you've got some shaded areas under just some ancillary info, essentially, to help you figure these out or whatnot or when you're trying to code them. So you look at our 28705, our pan-taylor arthrodesis, and the question underneath it are the shaded area. Where is this? And that's just helping you notify that that's when we're doing a calcaneocuboid with a talonevicular, a tibiotaylor, and a subtaylor arthrodesis, so a fusion at four different locations, versus our 28715 code, the arthrodesis, triple arthrodesis, where you've got your three locations, and that would include your calcaneocuboid, talonevicular, and subtaylor. Okay, now subtaylor, remember, stands for between the talus and the calcaneus, so making sure, again, so much of these are dependent on location, so you just want to make sure you're really paying attention in your documentation and then coders on the other end, those actual buzzwords in the documentation or educating our surgeons, whatnot, on how to dictate appropriately or document appropriately to make sure that they're catching all of those buzzwords for coding. Same thing goes here as we move into our mid-tarsals, our 28730 code. Remember, this is important where you've got multiple or transverse underlined in that code, and so that's important because, remember, you may have multiple fusion sites, but they're all included in one CPT code, so just making sure we're coding appropriately there, and then as we move forward a little bit, you've got your fusion codes for the toes as well noted here, and just one of, going back to our mid-tarsals, the code at the top of this table here, the 28740, just noting there in the underline, that's for the single joints. You're not going to use that for the multiple joints code. You're going to use our 28730 that we just discussed previously where it says multiple or transverse joints. All right, continuing on with our foot and ankle arthrodesis, remember, always be looking at your global service data guidelines for what is included versus excluded. You're going to see pretty heavily in the foot and ankle realm a lot of includes that, excludes that, and there may be some confusion there, so just make sure you're very well versed on looking at the GSD and seeing what is included, especially when you're doing something of a, you know, triple arthrodesis or whatnot. You've got lengthening of pendants, penalysis happening. At the same time, you're doing releases or repairs of the capsule and arthrotomies, so you just want to make sure you're really paying attention to the include and exclusion factor. All right, as we move through, we're going to talk a little bit about our Lisfranc injuries or Lisfranc fracture. Remember, that's an injury of the foot when you've got one or more metatarsal bones that are displaced from the tarsus. Now, the key is, again, for this is you want to look at the technique that's being used to repair your Lisfranc injury and be specific with your coding, and we'll talk about this far right column in just a moment. Just to touch on these two codes, you've got your 28615 code. That's the open treatment of the tarsal metatarsal joint dislocation, and of note there, remember, that does include internal fixation, so meaning if there's a fracture present at this joint, it's included in this treatment in this code, so it's not separately reportable, okay? Now, if you're going to, if you're a surgeon or if you are the surgeon, you're removing joint surfaces and doing that work prior to a fixation, that changes your code from that 28615 from a treatment of dislocation to now an arthrodesis code, which would be that 28730. So, again, it's depending on the technique that you're using for those repairs to determine, is this an open treatment versus an arthrodesis, okay? And, again, remember, we've got that 28740 at the very bottom. My apologies for jumping forward, but that is our single joint arthrodesis versus if it's multiple joints, you're going to use that 28730, all right? Now, in our far right column here, you will see the CMS MUE, so medically unlikely edits, and MAI as well, and basically medically unlikely edits are MUE adjudication indicators, tell us about the criteria that is necessary in order to support coding these separately. So when we come through here, that has an MAI value of three for your 28615, that open treatment, so value unlikely to appear on correctly coded claim, but in certain circumstances may be payable. And, again, always in that bold print writing, you're going to see you need supporting documentation. So I know we're going to say that a lot in this one hour, but the documentation is key. Please, physicians, help your coders and your billers do their job by providing them with as detailed and as critically detailed information as possible in your operative notes. Let's go over an example of this with our Liz Frank. This is an example note where we've got a pre- and post-operative diagnosis of a left-sided Liz Frank fracture, subluxation and dislocation, and a left second and third metatarsal base fracture. Now, remember, when you're looking at that very first procedure, our left-sided Liz Frank fracture, subluxation and dislocation, it's not very clear the way it's written right now for a selection of ICD-10. So, again, just as so in your op note, you want to always be clear with your pre- and post-operative diagnoses and specifically with the procedures that are being performed. So with this particular patient, we have three procedures being performed. You have open treatment with internal fixation of the right-sided Liz Frank fracture dislocation at both the first and the fourth TMT joint. We have a primary arthrodesis of right second and third tarsal metatarsal joint. And then our third procedure within this is the harvest of the left calcaneus autograft. We have a harvest taking place as well. So then we go to our questions is how are we going to code this? So how many tarsal metatarsal joint dislocations are repaired in this particular scenario? And the answer would be two. So that first and fourth TMT would be our TMT joint dislocations being repaired. How many mid-tarsal or tarsal metatarsal fusions were performed? And, again, the answer would be two, our second and third tarsal metatarsal joints. And then is there any overlap between the dislocation and these fusion joints? And the answer for this would be no. So now some payers treat all TMT joints as a single joint dislocation. That's not anatomically consistent with those CMS rules of MUEs. So in terms of this particular scenario, we would recommend that you can do multiple units of that 28615 for the treatment of those two different dislocation treatment sites. And then you'd have your 28730 with that modifier 51 for your multiple arthrodesis. And then, again, 59 to protect that bone grafting harvest. All right. As we move on, let's move on to some tendon procedures here. There's obviously a variety of CPT codes. We're going to focus on more of just some key concepts with these codes. So particularly you've got your primary repairs right there at the top, the 27658, followed by our 27659 and secondary repairs. Obviously primary, we're going to use those more for the repair of a new injury, versus secondary can be used in a variety of circumstances. Again, we've got our code for our extensor repairs and our flexor repairs. Again, while you're coding or looking at these codes, make sure you're very specific in your both documentation, but then also that you're reading these codes thoroughly because, again, there's a lot of little nuances, whether it's an extensor, a flexor, a primary, or secondary, with or without a graft. So make sure you're really getting down to the nitty-gritty of these codes. Now, another concept we have is our tenolysis codes here, and specifically we're looking at tenolysis of your flexor extensor tendons, our first code at the top there, the 27680. Now, keep in mind this is included in any repair of the same tendon. I'm going to repeat that again. Again, a tenolysis is included in any repair of the same tendon. So you would not code this for a repair of the same tendon as a tenolysis. You'd just do the repair code, okay? Now, we've got our lengthening or shortening of codes, and then obviously our gastrocnemius recession there. That's used a lot in pediatrics. I'm not sure if we have any peed foot and ankle with us today, but that's going to be used more in your pediatrics for your flat foot procedures, and that's that strayer procedure, where they're really just releasing the contractures in the lower leg in order to perform those procedures. All right. Again, in addition, we have a lot of transfer or transplant codes here. You want to match these descriptions back to your operative report, making sure that your operative report is well documented. Again, you've got that transfer of the transplant, and be specific for your superficial layer here in that 27690 code. And when it says superficial, they're giving the example here of your anterior tibial extensors into the midfoot versus your 27691, which are your deeper spaces. And there's quite a few examples there of what would be included in that, your posterior tibial through the interosseous space, your flexor digitorum longest, flexor hallucinus longest, and your perineal tendon to the midfoot or hind foot. You do have an add-on code there for each tendon as well. Remember, add-on codes are secondary, meaning you would have your primary code, and in addition to that, your add-on codes as well for each additional tendon, okay? Now, a lot of questions come out about transferring or transplant of single tendons or whatnot. CPT actually had a great note about this in 2021, an article where they said the transfer of the perineus brevis tendon to the perineus longest tendon should be reported as a superficial tendon transfer. And, again, this comes back to the concept of location, is where are those tendons in relation to themselves and where on the foot. So this would be classified as superficial, so you would be reported as a superficial tendon transfer. All right. Going into more of the documentation and coding tips for that, the key concept is here is that when you do a tendon transfer, to facilitate the repair of another injured tendon, remember you're only going to report that as a single code. You're not going to both report a transfer and a repair. And then per AOS guidelines, remember the tenolysis of a tendon that's also being repaired is inclusive within that repair. So you're not going to code a tenolysis for a tendon that you're also repairing. So it has to be a separate either pathological diagnosis or just a separate tendon altogether. And you've got some great examples of all of our CPT matrix here in your workbook as well. There's a lot of repair and tenolysis codes, but these now go more into the foot, again, being very specific about your flexors versus your extensors, primary versus secondary injuries with graft, without graft. It's very, very detailed in these coding examples. So make sure you're comfortable with those. And we actually coming up in a couple of slides here, give you a really nice breakdown of this. So I particularly love this matrix. It's a nice comparison table all in one location for those different types of codes. Again, the primary, secondary, with or without graft, whether it's tenolysis, tenotomy or whatnot for the ankle and the foot. So, you know, I've always said, give this to your billers, let them print this out and keep it on their desk side. Just a quick, easy reference guide to use. All right. We're moving along kind of quickly today. So try and slow us down just a little bit here. Moving into our ligament procedures. We've got, you know, multiple ligaments on both the medial side and the lateral side of the ankle. Now, how these are classified is as collateral ligament. So when you have, for example, the way that it's the, the way that it's set up here in this little graph, you've got your medial side with your tibial and avicular, your calcaneal tibial, anterior talotibial, and your posterior talotibial. On the lateral side, we do have our ATFL, our favorite little ligament there, our CFL, talocalcaneal, posterior talocalcaneal, and posterior talofibular. Now for the purposes of coding, our ATFL and our CFL are considered a single collateral ligament. Okay. And that comes into play. And we'll show some examples of that shortly of how that comes into play. But even though they're two separate structures, they can bind them as a single collateral. Okay. And when are you looking at our CPT codes, this comes into play here where you've got your 27695, which is the repair, primary repair of a disrupted ligament of the ankle collateral. Okay. So versus your 27696, where you've got again a repair of a primary disrupted ligament, but they call it both collaterals. Now, when they refer to both collateral, that means medial or lateral. Okay. Or excuse me, medial and lateral versus just a single collateral is considered medial or lateral. All right. So again, it's still dependent on location. Remember always that the ATFL and CFL are considered a single collateral ligament. And when they're deciding on these codes, you're looking at either both collaterals, meaning it's coming from a medial and lateral versus a single collateral, which is coming from just a medial or lateral. And then with our 27698 code on here, we've got a secondary repair for a disrupted ligament of the ankle, and it only specifies collateral. So you can see, there's no secondary repair code for both collaterals, like there is on the primary code. So for this, we would assume this would qualify then for additional units of this code, since there is no secondary repair code that includes both. All right. We'll give you a little example of this. So our case example here, we've got pre and post-operative diagnoses of left ankle instability. We also have a chronic peroneus brevis tear, and the procedure that was performed is a modified Brostrom lateral ligament reconstruction of our CFL and our ATFL. In addition, a peroneus brevis repair was performed. And for all intents and purposes, we'll consider that this or assume that this was a chronic tear being repaired on that peroneus brevis. All right. So now we're looking at our coding and we're going to see which codes will go together. So remember, we've got our modified Brostrom, which is a lateral ligament reconstruction of that CFL and the ATFL. As we talked about earlier, that CFL and the ATFL, remember, is treated as a single collateral ligament. So that would code for our 27698, where we've got a secondary repair of the collateral. In addition, we get that 27659 for our repair of our flexor tendon, secondary with or without a graft. And again, we're going to have that modifier 51 on there. All right. Now, as we move on to excision and curatage versus partial excision, we're not going to get into all of the little nuances about these, I just want to draw your attention to some of these. Obviously, all of these codes here use the term excision and curatage that are displayed on the screen. With that, remember, these codes, when they're referring to excision and curatage, a lot of times it's referring to, as it states in the description, of a bone cyst or a benign tumor. Remember, these are differentiated by their location, again, so location very important in foot and ankle coding and surgery, by the location of the foot. Remember, some of these will include an allograft, some will not. And now what we're going to compare these to would be our partial excision codes. So you've got your partial excision codes that come, that are typically used more in the case of something like an osteomyelitis. And again, that's in the description of the code, it's not all encompassing, but that's what we think of. So excision and curatage is more for a bony cyst or tumor, partial excisions are more for your osteomyelitis or treatments of osteomyelitis. Now this has left us kind of though with some big questions, as we always call it, Jen Bell's favorite term and mine is a conundrum, is that, you know, comes with a big question, particularly when your note or the physician note or the OPERA report discusses the use, the removal of an exostosis, so that growth of bone. And the reason is that the guidelines in CPT actually vary based on location for how these excisions of exostosis are removed. So you can see here at the top of the page, we've got a tibia and fibula location where it gives you an example of an exostosis excision code is that 27635. So it's specific to that in the tibia and fibula. Again with the phalanges of the foot, again, there's a code that takes place for partial excision of bossing or exostosis for the phalanges of the foot, you're going to use that 28124. Now, as you can see on the far right where the conundrum comes in is the tarsals and metatarsals. So there is no note for these locations, so we're kind of left to decide on which example to apply. Do we use the one that's more excision and curatage or do we use the partial excision? So that's where that little conundrum comes in. Now there was an expert, excuse me, an excerpt from CPT assistant in May 2011 that did kind of create more of a challenge in this regard because CPT assistant came out and said, well, they have this code, partial excision for osteomyelitis, talus or calcaneus, and it was noted that it's typically performed for an infection and not for an exostosis and only if a partial excision of the heel is performed. So what happened is payers have kind of latched onto that typically performed for an infection and not for an exostosis part of that and have been very critical of using that partial excision code when there's not an infection or diagnosis of an exostosis. So ultimately, we would say if you're trying to choose between excision curatage or partial excision code, we would definitely look for an increase in your complexity with a good supporting documentation that really shows your work in order to document appropriately and pick the code that you've chosen. So remember, it all comes down to that documentation. I'm going to keep harping on it, documentation. We live and die by that sword, so definitely continue being very specific in your operative reports and in your discussion in your operative reports of what you're performing. Now, CPT Assistant 2021 had a great question that come in where you can read this at your own leisure if you like. It really discusses what is appropriate when you're coding an OCD lesion, present and drilling is being performed for that service. You want to make sure you touch base on this. Essentially, there is not a CPT code that really describes the open drilling of an osteochondral defect of the talar dome. So for this, we would consider that an unlisted code. So you'd still use that 27899 code for unlisted procedure of leg or ankle. That's something just to refer back to or take a look at that CPT Assistant. Now, for those of you who are doing Hallis-Daugus and Hallis-Brigidus, these codes changed several years ago to really no longer include physician names and techniques and instead are really defined by the type of osteotomy work that's being utilized for these procedures. So again, something to be very specific about. You have your Hallis-Brigidus without implant and our 28289 code. With an implant, it's 28291. As we come down to our bunionectomies, our 28292 or Hallis-Daugus correction. Remember, this is all about where the bone cuts are actually being made and the work being done at the MTP joint to align that MTP joint, excuse me, correctly. So remember, you might use a resection of the proximal salient or distal proximal osteotomy in conjunction with your treatment. You just want to make sure you're very specific as where these cuts are being made. As you can see, there's a lot of additional codes of that bunionectomy here, either with a distal metatarsal osteotomy, a proximal metatarsal osteotomy with a proximal salient osteotomy, depending on the, you know, not method specific or a double osteotomy. So there's a lot of codes that can be utilized there. You want to be, again, very specific as to where these bone cuts are being made. All right, we move on. These are three CPT codes used with frequency during the same operative session as your Hallis-Daugus correction. Most specifically is the one actually below the star, the 28285, our correction hammer toe is the most commonly used code along with your bunionectomies. Again, that capsulotomy code, again, is a separate procedure of the metatarsal phalangeal joint with or without tenorfa, okay? So making sure you're really coding these appropriately as well because we can use that your hammer toe in conjunction with your Hallis-Daugus correction. Now, as we come into this again, remember, we're going to keep coming back to this is that you always want to refer to your global service data guidelines as far as the inclusion and exclusion. So even within this procedure of our Hallis-Daugus bunionectomy, you've got your tenotomy, your lengthening, your release of abductor hallucis muscles are included, and then excluded in that 28296 down below is the lengthening of the tendon of the ankle. So again, if you're going to perform that, you want to give a very good documentation as to why it should be included. And per AOS deadlines, the lengthening of that is excluded from the actual primary Hallis-Daugus correction code. So just your documentation tips. Remember, you always want to be very specific as far as what is actually being cut, you know, what is included is obviously your arthrotomy, your capsulotomy, those biopsies, and the tenolysis and whatnot. Per AOS, they're still saying lengthen your shortening of the tendons is excluded from those that procedure from that primary procedure. The more documentation tips here again, when osteotomy is performed in conjunction with your bunionectomy, it is again not appropriate to report osteotomy codes separately for work on the same metatarsal or proximal phalanx. So we'll go through a question of that and show you what's included, excluded in that Hallis-Daugus. So we've got our 28285. Remember, again, you've got the arthrotomy, the tenotomy, capsulotomy for the joint contracture all included. And then in our exclusion criteria, you've got capsulotomy for contracture and metatarsal phalangeal joint with or without center athery, single each joint. So question is, is 28270 separately reportable with our 28285? OK. So is our capsulotomy separately reportable with that hammertoe correction? And for these GSD guidelines, it is separately reportable if there's a supporting diagnosis, a separate supporting diagnosis of the contracture at the MTP. So as long as you have that diagnosis for contracture, you can make an argument towards having, you know, even though they're close in location, it's a separate, you know, separate identifiable diagnosis. So the treatment could be warranted. So you want to make sure, again, comes back to that sword we talked about, really documenting appropriately. All right. And then just some tips from CPT assistant. Again, making sure you always look at that CPT assistant. We've got the 28285, their hammertoe correction, including the resection of the proximal phalanx, your flexor tenotomy at the DIP, and insertion of K-wire through DIP, MTP, and PIP joints. Whereas 28285 can be used for correction of quads as well when performing extensor tenotomies with flexor tendons in the toe. All right. Getting into, last but not least, our ostectomy and our osteotomy codes. Remember, our osteotomy, that removal of bone versus our osteotomies is the changing of the alignment of the bone. Again, we're just going to review some of these codes just to point out the differences between them here. In the middle of the page, we've got our osteotomy, excuse me, osteotomy of the calcaneus. Again, that'd be noted to be used more for your Haglund deformities or you're moving that bone on the back of the heel. And that's in reverse of your 28119, your ostectomy, excuse me, osteotomy calcaneus for a spur with or without a plantar release. And that's on that plantar side of the calcaneus. So just a little bit of distinguishment there between the Haglund and your traditional bone spurring on the bottom of the calcaneus. All right. Now, there is a little bit of a challenge here for this 28300, our osteotomy of the calcaneus and does note a few different examples of techniques and Dwyer-Chambers type procedure with or without internal fixation. Remember, a physician does two osteotomy cuts within the calcaneus. And so we've always believed that it should qualify for multiple units. However, we've got to always look at those MCCI edits and really stay up on those where you do have an MCCI edit, they put an MUE or medically unlikely edit equal to one, which was previously not appealable. But late 2021, the Academy AOS met with MCCI and the MUA was actually changed to a two, making it a little bit easier to be paid. So not guaranteed, but easier. So, as I always say. All right, moving on to a little bit more of these codes. Remember, you've got your 28308, our osteotomy codes. Let's just go to our 28304, which is on your page. Remember, you've got your osteotomies of your tarsal bones, which would be like your cotton osteotomy, with or without allograft is used there. Here we've got our 28308. Remember, this is an osteotomy of your metatarsal, other than the first metatarsal. So remember, it's often seen in conjunction with your adjacent metatarsal when you also have like a hammertoe correction or a capsulotomy. Remember, you can code these together if there is a supporting diagnosis. So remember, you want to have that contracture diagnosis at the MTP joint to really allow for these codes to be used in conjunction with each other. And then we've got our 28310 again, our osteotomy, our shortening or angular rotation correction. Remember, this is where your surgeon is making cuts to the bone, possibly removing wedges, realigning, and then fixating. All right. And there's actually a great article, if you'd like. You can take a look at this at your leisure as well. There's a confusion continues over reporting more than one calcaneous osteotomy. So it's not just us, everybody. There's articles out there going over this as well. Definitely want to take a look at this in your AOS now for your April 2022 edition. All right. Let's move on to getting into some of these foot and ankle exercises. Now we'll have plenty of time for some Q&A at the end here. So we've got a physician who performs a left house valgus correction with distal metatarsal osteotomy. And for this, we would give that code of a 28296. All right. Our next exercise, we have a physician who performs a left house valgus correction with a distal metatarsal osteotomy and a proximal phalanx osteotomy. So remember, in this situation, we would have to code a 28299. All right. Now we have our physician who performs a transfer of the right peroneus brevis to repair the peroneus longus. Remember, we talked about this earlier. This is considered a superficial tendon transfer per that CPT assistant guideline. So notice this is for leg and ankle and not in the foot. This would be that 27690 code. All right. We've got a physician who excises a posterior spur and the retrocalcaneal bursa at the calcaneus. The Achilles tendon is frayed, and the physician performs debridement above its insertion site. Again, we've got that Achilles tendon tenolysis, so the extensor in the leg or ankle. So we're going to go with that 28118 and our 27680 with that modifier 59. Okay. Now a patient with midfoot arthritis. The physician performs an arthrodesis of the calcaneal cupoid joint and an arthrodesis of the talonevicular joint without tendon transfer. All right. So now, remember, we've got our midtarsal joint. We've got multiple midtarsal joints. So we're going to go with that 28730. Remember, there's that 28740, which is a single joint, but we would not use that with multiple units. Instead, we would use this multiple joint code, the 28730. All right. And then lastly, we've got a physician who documents excision of a phalangeal exostosis. There is no mention of infection or other bone disease. So with this, remember, you always want to consider what is the bone location. Are we going to call this an excision and curatage or a partial excision? And for this example, we would recommend a 28124 for this code. All right. And that's that partial excision code. All right. So a couple of things to draw your attention to in your handbook, we do, in your handout, we do have some resources for you. Again, always reviewing those modifiers for your surgical modifiers, your 50, 51, 59, your 76s for those repeat procedures. Again, our 58s and 78s, so stage-related procedure during your post-op period, that unplanned return to the OR for a related procedure during your post-op period, and an unrelated return. So again, remember, just looking in your, there is a downloadable resource for this and also in your handbook as well. Gives you a nice breakdown of examples and when to use these modifiers, as well as operative report dictation tips for coding and for appeals as well. All right, guys. That's all we have for today. We can definitely go through some Q&A. Thank you so much for your time. I hope we covered everything that you've been wanting to know. And then I'll turn it over to Jen Bell to take us through some Q&A if we have any. All right, Jen. Thank you for that presentation. That was awesome. We do have one where, well, this is not related to the, this is more of an operational issue. Where do we find the handout? The handout will be under the chat. So that's where you can find the handout. And we do have a question here about, excuse me, talking about the superficial let's see, 27690. And the question is, why is this a 27, the transfer of the peroneal brevis tendon to the peroneus longus tendon? Why is it 27690 and not 27691? And I believe the 91 would be that deep tendon transfer. Yeah, so remember we talked about that CPT assistant article that came out in May 2021. Essentially, it all comes down to that location. So thank you, Jen Bell. So location is, remember, when you transfer the peroneus brevis tendon to the peroneus longus tendon, they're stating that per CPT assistant, it should be reported as a superficial tendon transfer code, which is that 27690. So remember, it's superficial. It's a part of that midfoot. The 27690, excuse me, they're treating that as the redirecting or rerouting of those single tendons together. So that's per CPT assistant recommendations. I don't know if you have any additional to touch on that, Jen. No, that sounds really good. Thank you. Great answer. Yeah, don't show anybody else have any questions for us. You, now's the chance. If you do have questions, just post them in the Q&A and we'll give another minute or so here for that. Well, let's see. Just a second. Let's see this. Here's one Jen and I don't know if you want to answer this now. Let's see, or you might want to get. Take a minute on this one. The Chevron, the Chevron Aiken osteotomy need to always be billed with double osteotomy. Or is it separate. That's a great question actually have notes on that give me one second while I pull those up. All these codes get jumbled in my brain sometimes so let me look up and see if I can find that really quickly. And the handout should be both handouts are in the chat while Jen is taking a look at that. I see them here. We'll ask Jennifer more, would you mind posting those, perhaps, maybe even in the I don't know if you can post in the q amp a, but the handouts are both in. Yeah, actually she did post it twice in the chat, not the q amp a but the chat function. I don't have an answer. As of right now for Jeremy about the Chevron Aiken osteotomy always need to be billed with a double osteotomy or separately. Let me get back to you on that I just need to review some of the edits and see. Because if the diagnosis typically if the diagnosis is for bunion. Part of that 282 would be angular correction, so it would need a supporting diagnosis. Let me just let me get back to you and I want to look at some of the edits and see if it always needs to be billed double or separately. I apologize I don't have an answer right now but I will look into it and get back to you and we'll be, I believe that there'll be posting these for you guys to see as well so the q amp a answers get posted. Thank you, Jen. I actually was going to say the same thing. It depends on the diagnosis and we just want to. Oh, good. All right. So people are finding the handouts now so that's great. And any more questions out there. I think that is it. Perfect. Well, thank you everyone so much again for joining us. We really appreciate your time on a Tuesday in the middle of the day, and let us know if you have any additional questions and again Jeremy will get back to you with the answer to your question as soon as possible. Thank you guys so much for your participation we really appreciate it. Have a great day.

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