Haglund's deformity - billing

[DYK343]

I have seen this billed different ways as a resident.

Curious everyone's take on this common billing scenario: Achilles take down, resection haglund's, resection of bursa, debridement of the Achilles, reattach Achilles. (with or without FHL tendon transfer which is obviously its own separate code).

How would you bill out this case?

Bill only 28118 (ostectomy haglunds) OR 28120 (partial excision calcaneus) - achilles repair (debridement?) is included in this code

Or

Add on 27650 for Achilles tendon repair - debridement

Or

Add on 28090 for removal bursa



Personally I bill this as 28118 and forgo 27650 unless I actually do significant Achilles debridement then I do add on 27650 (and FHL transfer). I have never billed bursa excision but I know people who do. I also know people who say 27650 is not billable even with Achilles debridement.

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[wakaflocka88]

I have been billing only 28118 since I feel this code is all inclusive, minus the FHL. But I feel if you/I debrided >50% of the distal Achilles then we are already probably looking at a FHL augmentation anyways. Just my thoughts.

My other question now is when it comes to Peroneal work - if a PL to PB anastomosis was done with fibular groove deepening, augmentation of SPR due to bad Peroneal damage, how would you bill this? All one code or break it down?

 

[icebreaker32]

I bill 28118 and add either 27650 or 27654 only when I really need to debride and excise calcified tendon.

 

[air bud]

Are we talking Medicare or BCBS....?🤔

 

[DYK343]

I have been billing only 28118 since I feel this code is all inclusive, minus the FHL. But I feel if you/I debrided >50% of the distal Achilles then we are already probably looking at a FHL augmentation anyways. Just my thoughts.

My other question now is when it comes to Peroneal work - if a PL to PB anastomosis was done with fibular groove deepening, augmentation of SPR due to bad Peroneal damage, how would you bill this? All one code or break it down?

27676 repair dislocating peroneal tendons with fibular osteotomy

 

[DYK343]

Are we talking Medicare or BCBS....?🤔

both

 

[Feli]

27654 and 28118, document appropriately for basic Haglund with insertional and/or watershed area tendonitis.
If there isn't at least some tendon pathology and chronic scarring, then I'm not sure conservative care was exhausted.

...Peroneal work - if a PL to PB anastomosis was done with fibular groove deepening, augmentation of SPR due to bad Peroneal damage, how would you bill this? All one code or break it down?

Inject and Arizona brace and topical diclo or lido or whatever... let some other surgeon give them CRPS
Or do osseous-based recon? (fix the ankle varus, RF cavus, midfoot cavus, etc)

I honestly can't remember the last time I did any direct peroneal stuff besides taking out os peroneum or acute total rupture (which is rare to not be an avulsion fx instead). I feel that stuff just all scars down anyways; I don't believe the peroneals move very well and/or the biomech fault that strained them is not being addressed. I think it's pretty futile to do peroneal tendon repair "longitudinal tears," debride, graft, retinaculum, anastomosis... just like an isolated PT tendon repair or FDL xfer or spring lig repair is futile in a flat foot. The osseous work is just so much more durable and reliable. We have to think of the biomechanics more than just the MRI reports.
I can count the number of patients I've seen who have a big scar over the peroneals from St Elsewhere (often good board cert surgeons)... and I need to counsel them on brace options, topical pain options, inject options, PT options, Dwyer and fusion salvage options, etc... it is in the high dozens or low hundreds for sure. It is really not fun to see that bad function and chronic sural pain in 30 and 40-somethings who were active beforehand but now struggle mightily to do that same stuff.

(edit to add: this is not to say lateral stabs don't work well.. those often work very well and use small pretty safe incision. But peroneal recon? YMMV, not my jam)

 

[DYK343]

I have had zero success with Dwyers. Not powerful enough. I started lateralizing Dwyers and they got tarsal tunnel symptoms.
I havent done one yet but Z osteotomy will be my next cavus procedure. Im done with Dwyer and lateral calc osteotomy.

 

[wakaflocka88]

27654 and 28118, document appropriately for basic Haglund with insertional and/or watershed area tendonitis.
If there isn't at least some tendon pathology and chronic scarring, then I'm not sure conservative care was exhausted.


Inject and Arizona brace and topical diclo or lido or whatever... let some other surgeon give them CRPS
Or do osseous-based recon? (fix the ankle varus, RF cavus, midfoot cavus, etc)

I honestly can't remember the last time I did any direct peroneal stuff besides taking out os peroneum or acute total rupture (which is rare to not be an avulsion fx instead). I feel that stuff just all scars down anyways; I don't believe the peroneals move very well and/or the biomech fault that strained them is not being addressed. I think it's pretty futile to do peroneal tendon repair "longitudinal tears," debride, graft, retinaculum, anastomosis... just like an isolated PT tendon repair or FDL xfer or spring lig repair is futile in a flat foot. The osseous work is just so much more durable and reliable. We have to think of the biomechanics more than just the MRI reports.
I can count the number of patients I've seen who have a big scar over the peroneals from St Elsewhere (often good board cert surgeons)... and I need to counsel them on brace options, topical pain options, inject options, PT options, Dwyer and fusion salvage options, etc... it is in the high dozens or low hundreds for sure. It is really not fun to see that bad function and chronic sural pain in 30 and 40-somethings who were active beforehand but now struggle mightily to do that same stuff.

(edit to add: this is not to say lateral stabs don't work well.. those often work very well and use small pretty safe incision. But peroneal recon? YMMV, not my jam)

Thanks for all the pointers. My question was asked above as I do have a lady with a 1 month old PL rupture at level of os Peroneum with 2-3cm gap on MRI. I told her chances of fixing it end to end is slim as it’s likely retracted from walking so that’s why I was thinking of trying to anastomose the proximal part if I can’t find the distal part and then just lateral stab her ankle to lock it more and if other fibula groove/SPR needs to be done either.

I also have a fair amount of chronic ATFL patients that need ankle stab +\- internal brace and like you said, majority will have MRI findings of Peroneal Brevis “tears”. I feel that since I’m already in that area with my single incision, I might as well evaluate and suture it back up if that’s the case. But I don’t have enough experience to say if an isolated ankle stab will solve the Peroneal tears that MRI always pick up. Sometimes it’s difficult on exam to completely isolate if it’s a mixed lateral ankle pain versus isolating lateral gutter from Peroneals

 

[air bud]

27654 and 28118, document appropriately for basic Haglund with insertional and/or watershed area tendonitis.
If there isn't at least some tendon pathology and chronic scarring, then I'm not sure conservative care was exhausted.


Inject and Arizona brace and topical diclo or lido or whatever... let some other surgeon give them CRPS
Or do osseous-based recon? (fix the ankle varus, RF cavus, midfoot cavus, etc)

I honestly can't remember the last time I did any direct peroneal stuff besides taking out os peroneum or acute total rupture (which is rare to not be an avulsion fx instead). I feel that stuff just all scars down anyways; I don't believe the peroneals move very well and/or the biomech fault that strained them is not being addressed. I think it's pretty futile to do peroneal tendon repair "longitudinal tears," debride, graft, retinaculum, anastomosis... just like an isolated PT tendon repair or FDL xfer or spring lig repair is futile in a flat foot. The osseous work is just so much more durable and reliable. We have to think of the biomechanics more than just the MRI reports.
I can count the number of patients I've seen who have a big scar over the peroneals from St Elsewhere (often good board cert surgeons)... and I need to counsel them on brace options, topical pain options, inject options, PT options, Dwyer and fusion salvage options, etc... it is in the high dozens or low hundreds for sure. It is really not fun to see that bad function and chronic sural pain in 30 and 40-somethings who were active beforehand but now struggle mightily to do that same stuff.

(edit to add: this is not to say lateral stabs don't work well.. those often work very well and use small pretty safe incision. But peroneal recon? YMMV, not my jam)

respectfully disagree about peroneal tears. I have fixed a lot of them and am happy with the results. Chronic peroneal pain, failed 4-6 weeks in a boot? MRI. And I warn them that the MRI may not be accurate (magic angle effect). Tear? Surgery. No tear? try PT for a month or so and if still pain then still surgery. More than 50 percent of the time when no MRI tear I still see pathology. Don't see anything? Low lying PB take some of it out....don't have anyone I can think of that had continued peroneal pain after surgery.

 

[DYK343]

respectfully disagree about peroneal tears. I have fixed a lot of them and am happy with the results. Chronic peroneal pain, failed 4-6 weeks in a boot? MRI. And I warn them that the MRI may not be accurate (magic angle effect). Tear? Surgery. No tear? try PT for a month or so and if still pain then still surgery. More than 50 percent of the time when no MRI tear I still see pathology. Don't see anything? Low lying PB take some of it out....don't have anyone I can think of that had continued peroneal pain after surgery.

The peroneals do great! The sural not so much... At least in my experience

The sural nerve is my most hated nerve. its full of problems in my experience

 

[air bud]

Thanks for all the pointers. My question was asked above as I do have a lady with a 1 month old PL rupture at level of os Peroneum with 2-3cm gap on MRI. I told her chances of fixing it end to end is slim as it’s likely retracted from walking so that’s why I was thinking of trying to anastomose the proximal part if I can’t find the distal part and then just lateral stab her ankle to lock it more and if other fibula groove/SPR needs to be done either.

I also have a fair amount of chronic ATFL patients that need ankle stab +\- internal brace and like you said, majority will have MRI findings of Peroneal Brevis “tears”. I feel that since I’m already in that area with my single incision, I might as well evaluate and suture it back up if that’s the case. But I don’t have enough experience to say if an isolated ankle stab will solve the Peroneal tears that MRI always pick up. Sometimes it’s difficult on exam to completely isolate if it’s a mixed lateral ankle pain versus isolating lateral gutter from Peroneals

yeah just anastamose. More about pain generation of the tear, so just suture it side to side or that pulver whatever graft. Never done a true graft like that crazy staged FHL transfer. And if true acute tear, may consider just a turn down flap. I mean if we are willing to debride 50 percent of the tendon and they do good, then why not do a turn down and get it reattached at 50 percent.

 

[air bud]

The peroneals do great! The sural not so much... At least in my experience

The sural nerve is my most hated nerve. its full of problems in my experience

no sural nerve problems yet....but I know they are headed my way. PARS this friday maybe I will get lucky.

 

[wakaflocka88]

respectfully disagree about peroneal tears. I have fixed a lot of them and am happy with the results. Chronic peroneal pain, failed 4-6 weeks in a boot? MRI. And I warn them that the MRI may not be accurate (magic angle effect). Tear? Surgery. No tear? try PT for a month or so and if still pain then still surgery. More than 50 percent of the time when no MRI tear I still see pathology. Don't see anything? Low lying PB take some of it out....don't have anyone I can think of that had continued peroneal pain after surgery.

Do you Prefer a single curvilinear incision behind the fibula to do both your Peroneal work and ankle stab?

 

[Feli]

I have had zero success with Dwyers. Not powerful enough. I started lateralizing Dwyers and they got tarsal tunnel symptoms.
I havent done one yet but Z osteotomy will be my next cavus procedure. Im done with Dwyer and lateral calc osteotomy.

Yeah, Dwyer is not enough for bona fide semi-rigid or rigid cavus feet with sub 1,5 calluses, hammertoes, etc. I usually do re-align STJ or triple (STJ has almost zero ROM on true cavus foot anyways) for those for the transverse component, TAL saggital, something medial column for saggital (DFWO, Jones, dorsiflex TN in triple, etc). They almost always need hammertoes across the board too. I approach the cavus like a flat foot usually: posterior lengthen, hindfoot realign, and medial column... maybe more. I have never done a Cole... that is one I may punt since I can't see it ending well?

For lateral ankle issues with the much more common mild flexible cavus (or even rectus that just keeps having invert/unstable issues), Dwyer can be really good (usually in conjunction with scope + stab). These are those reducible mild cavus with ankle symptoms. I leave medial cortex intact, but you can take out as reasonably big of a lateral wedge as you like.

I agree to avoid the sharp corners with the calc displacements also (and screws not staple or plaple crap), but I don't do a lot of Kouts slide on flatfoot either unless maybe it's a kid (underpowered for adults). I have seen a ton of those xrays with Kouts done (probably with MBA!) that it did nothing for the flat foot, who is now adult who is in my office for arthritic flat foot. Evans is a ton more powerful on those.

respectfully disagree about peroneal tears. I have fixed a lot of them and am happy with the results...

...Yeah, I'm not saying peroneal stuff doesn't work overall, I just don't like doing it.

I am probably biased since there are a few surgeons who are/were in my current area who seem to think wrapping peroneals (and the sural) up in amnio wrap and bunch of sutures is their gold standard for any lateral hindfoot pains. I have the pt get the op report if I can't tell from XR what they had. A lot of them are now complaining of barely able to wear a shoe, fire on the heel, zingers up towards the ankle, etc... asking me for fix ideas... and my only idea is pretty much Pain Mgmt referrals or AFO; it sucks. I am less fazed by that on trauma pts, but these are people with probably ankle sprain symptoms who had elective surgery. It is not cool to see sub-50 people who are disabled or headed that way... from elective.

 

[air bud]

Do you Prefer a single curvilinear incision behind the fibula to do both your Peroneal work and ankle stab?

2 incision. I do straight incision for ATFL. Fibula to talus

 

[air bud]

I have had zero success with Dwyers. Not powerful enough. I started lateralizing Dwyers and they got tarsal tunnel symptoms.
I havent done one yet but Z osteotomy will be my next cavus procedure. Im done with Dwyer and lateral calc osteotomy.

I have never and will never do a cavus recon.

 

[DYK343]

I have never and will never do a cavus recon.

Smart man. They really dont do great. Especially with the sural neuritis they all develop.

I have never done a Cole... that is one I may punt since I can't see it ending well?

I did some in residency and I agree. Absolutely crazy procedure. I didnt have long term follow up but no way I would ever do that to someone and certainly wouldnt want it done to myself - ever.

wrapping peroneals (and the sural) up in amnio wrap

Absolute witchcraft. They do it around here. Amnio causes tons of problems and pads reps pockets along the way.

not staple or plaple crap

The Plaple. The most ridiculous orthopedic device on the market. I challenge anyone to find something more dumb and post it.

 

[wakaflocka88]

I have never and will never do a cavus recon.

100% agree. Only did a few in residency, I’m not good enough to touch these. But I know fresh fellows around that will gladly surgerize 😉

 

[dtrack22]

I have seen this billed different ways as a resident.

Curious everyone's take on this common billing scenario: Achilles take down, resection haglund's, resection of bursa, debridement of the Achilles, reattach Achilles. (with or without FHL tendon transfer which is obviously its own separate code).

How would you bill out this case?

Bill only 28118 (ostectomy haglunds) OR 28120 (partial excision calcaneus) - achilles repair (debridement?) is included in this code

Or

Add on 27650 for Achilles tendon repair - debridement

Or

Add on 28090 for removal bursa



Personally I bill this as 28118 and forgo 27650 unless I actually do significant Achilles debridement then I do add on 27650 (and FHL transfer). I have never billed bursa excision but I know people who do. I also know people who say 27650 is not billable even with Achilles debridement.

27687
28120
27654 (not sure why people are billing 27650, that’s a primary repair, like for an acute problem)

The achilles repair is assuming I remove a significant portion of the achilles. Most of the time I’m billing it

 

[wakaflocka88]

27687
28120
27654 (not sure why people are billing 27650, that’s a primary repair, like for an acute problem)

The achilles repair is assuming I remove a significant portion of the achilles. Most of the time I’m billing it

You code all 3 for a haglund?? Dang I’ve been way underbilling for my RVUs

 

[DYK343]

27687
28120
27654 (not sure why people are billing 27650, that’s a primary repair, like for an acute problem)

The achilles repair is assuming I remove a significant portion of the achilles. Most of the time I’m billing it

Do you always do a gastroc/27687?

 

[PatchAdamsFan]

I code 27687, 28120, 27654 - exactly as dtrack stated. Gastroc on almost everyone. In fact, I did it solely for a couple haglunds and their pain is gone. Huge component imho.

And maybe I'm still bushy-tailed, but I have no problem doing non-CMT cavus recons..

 

[dtrack22]

Do you always do a gastroc/27687?

Almost always, yes.

You code all 3 for a haglund?? Dang I’ve been way underbilling for my RVUs

Not for an isolated haglunds, but for the scenario/case described by the OP in the actual post, yes, I bill all 3. Never add any bursae or posterior capsule or compartment release codes. I’ve seen people add those on to everything else mentioned…

 

[air bud]

Almost always, yes.



Not for an isolated haglunds, but for the scenario/case described by the OP in the actual post, yes, I bill all 3. Never add any bursae or posterior capsule or compartment release codes. I’ve seen people add those on to everything else mentioned…

I don't see how that FHL tendon is moving without "releasing" the deep compartment fascia....

 

[dtrack22]

I don't see how that FHL tendon is moving without "releasing" the deep compartment fascia....

Those farm animals don’t pay for themselves…

 

[Feli]

I do gastroc on the miniority of my Haglunds (but code it when you do it), but I do them on nearly all of my Achilles primary (rupture) repairs... and code accordingly.

I do the gastroc a lot deeper and into the soleus than I do for just bunions, flat foot, etc... I'm trying to get major length for the Achilles ruptures.

 

[DYK343]

I do gastroc on the miniority of my Haglunds (but code it when you do it), but I do them on nearly all of my Achilles primary (rupture) repairs... and code accordingly.

I do the gastroc a lot deeper and into the soleus than I do for just bunions, flat foot, etc... I'm trying to get major length for the Achilles ruptures.

Yeah I havent done many gastrocs for Haglunds with takedown. I get why someone would do it but I havent had any issues not doing it (that I know of).

V toY with FHL transfer to heeal is my go to for Achilles ruptures that need length. Zero issues and happy patients with this method.

Do you get hematoma issues cutting through the gastroc that deep? (Not that V to Y doesnt pose same risk...)

 

[Feli]

...Do you get hematoma issues cutting through the gastroc that deep? (Not that V to Y doesnt pose same risk...)

I do that aggressive lengthen for neglected Achilles ruptures open, extend single incision up for gastroc (I do V-Y also ), then bovie cut the soleus below if gastroc wasn't enough, and then maybe coag soleus if any bleeders. I barely ever see Achilles ruptures that aren't neglected for weeks of limping around and contracted in middle age or older guys (the college girls that tore theirs 3 days ago with a 1cm gap must be going to ortho?).

A major way to prevent hematomas for any surgery is I do those (and almost any Achilles/gastroc surgery... and nearly any forefoot) wet - but with cuff on just in case... so I think that helps the pt pain and also helps me... like any wet surgery, you see if you hit anything significant that needed more coag. Even for RRA stuff, I let cuff down while I'm closing. I have not had a hematoma on Achilles tear + V-Y... just the usual suture granuloma and post-op equinus that I think anyone who does neglected Achilles ruptures has had, lol.

For most regular gastrocs (meta, TAL, flatfoot, etc), I just do supine frog leg medial approach (wet)... wouldn't intentionally mess with soleus there since you don't need more length and don't have good ability to control a big vein or something through that little ~3cm window incision. I just separate aponeurosis layer blunt (so should be deep to sural) and then cut the aponeurosis with mayo or scalpel + malleable. That's how I do them with a Haglund if needed.

It never made sense to me to use tourniquet on Achilles, gastroc/TAL, Haglund, etc prior to incision. Most of my residency attendings used cuff up, but they barely bleed a drop, esp you use epi lido. I usually want to save that tourniquet time also if it's a major recon (flat, cavus, Charcot, etc) where they have many more procedures or even need to go prone-to-supine after the TAL is done.

 

[air bud]

Always find the tourniquet discussion interesting. Except for amputations I use a tourniquet for everything. Very rarely do I drop it prior to closing. Yes have probably had some hematomas that caused the patient's pain and do get a lot of bleeding into the dressing postoperatively but have never had a true hematoma that required drainage and revision surgery. Every once in awhile when I do decide to drop the tourniquet prior to closing, I always wonder why I did this because I hate closing wet. From time to time I check in with my friends and see if they are doing anything different and everybody that I know that trained at different programs across the country I'll use a tourniquet large majority of the time and don't drop it until they are all closed and dressing is on.

Edit, I will close the skin of hammer toes wet usually at least when you using k wires to make sure that they pink up.

 

[DYK343]

I like my tourniquets. I dont like working in a bloody hole. Especially if around a nerve or artery. An Austin bunion sure. Midfoot fusion? No thanks.

I get some minor post op bleeding issues but I agree never any hematomas that needed evacuated surgically.

I dont think the incisional scar is as cosmetic as when no tourniquet is used.

No tourniquet = no bleeding = barely visible scar.

Tourniquet = post op bleeding = ugly incisional scar

 

[ExperiencedDPM]

28118 is the correct code for the bone work. 28120 is incorrect. I assure you I am correct on this issue.

In addition, if you are not truly doing a repair, 27680 which is a tenolysis is also a code to consider depending upon your actual procedure.

27654 is okay as long as there is significant debridement of tissue.

It is NOT appropriate to bill for the bursa excision.

Unbundling is HIGH on the insurance companies radar. If you want a free pass to the top of the radar list, keep unbundling procedures. You’ll get there quickly.

Read NCCI policy regarding component procedures and surgical approach.

 

[air bud]

Have always been confused on 28118 vs 28120. Good to know. And yeah I only do 27654 when truly debriding tendon. Pretty quick to go to FHL if cut out more than 25 percent of the tendon.