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Certificate of AttendanceAdvanced Clinic: Podiatry CPT
Coding
March 11, 2004
_____________________________________NAME
Lolita M. Jones, RHIA, CCSPresenter
The American Health Information Management Association (AHIMA)
has approved this program fortwo (2) continuing education clock
hours in the External Forces content area.
Retain this certificate as evidence of participation.
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Advanced Clinic PodiatrySurgery
All CPT Codes 2003 American Medical Association * Lolita M.
Jones Consulting Services 1
Advanced Clinic:
Podiatry Surgery CPT Coding
Author:
Lolita M. Jones, RHIA, CCSLolita M. Jones Consulting
Services
1921 Taylor Avenue
Fort Washington, MD 20744
(V) 301-292-8027
(FAX) 301-292-8244
Coding Training: www.hcprofessor.com
E-mail: [email protected]
Distributed by HCPro, Inc.
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All CPT Codes 2003 American Medical Association * Lolita M.
Jones Consulting Services 2
TABLE OF CONTENTS
Disclaimer 3
About Lolita M. Jones Consulting Services 4
I. Introduction 9
II. Clinical Coder: Skeletal Anatomy of the Foot 10
III. Toe Modifiers 15
IV. CPT Coding Tips 16
V. Case Studies 17
VI. Sample CPT Audit Findings 50
VII. Case Studies Answer Key 52
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Disclaimer
Advanced Clinic: Podiatry Surgery CPT Coding is designed to
provide accurate and authoritativeinformation in regard to the
subject covered. Every reasonable effort has been made toensure the
accuracy of the information within these pages. However, the
ultimate responsibility lies withthe user.
Lolita M. Jones Consulting Services and staff make no
representation, guarantee or warranty, express orimplied, that this
compilation is error-free or that the use of this publication
willprevent differences of opinion or disputes with Medicare or
other third-party payers, andwill bear no responsibility or
liability for the results or consequences of its use.
Physician’s Current Procedural Terminology, Fourth Edition
(CPT-4) is a copyrighted coding systemowned and maintained by the
American Medical Association.
Please contact Lolita M. Jones, RHIA, CCS at:(V)
301-292-8027(Fax) 301-292-8244Coding Training: www.hcprofessor.com
E-mail: [email protected]
� 2004 Lolita M. Jones Consulting Services
All five-digit number Physician’s Current Procedural
Terminology, Fourth Edition (CPT) codes, servicedescription,
instructions and/or guidelines are � 2003 American Medical
Association. All rights reserved.
All rights reserved. The author grants permission for
photocopying for limited personal use or internal useof the
original purchaser. This consent does not extend to other kinds of
copying, such as for generaldistribution, for advertising or
promotional purposes, for creating new collective works, or for
resale.
PODIATRY
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About Lolita M. Jones Consulting ServicesHOSPITAL TRAINING
PROGRAMS
Coding Training: www.hcprofessor.com(V) 301-292-8027
(FAX) 301-292-8244E-mail: [email protected]
BIOGRAPHY:
Lolita M. Jones, RHIA, CCS, is an independent consultant
specializing in hospitaloutpatient and ambulatory surgery center
coding, billing, reimbursement, and operations.Ms. Jones recently
launched her web-based coding program at www.EZMedEd.com. Shehas
over 15 years of experience in publishing, training, and auditing
for the hospitaloutpatient and freestanding ambulatory surgery
center (ASC) markets. Ms. Jones hasearned both the Registered
Health Information Administrator and Certified CodingSpecialist
credentials from the American Health Information Management
Association(AHIMA) in Chicago, IL. Ms. Jones resides in Fort
Washington, Maryland, and she hasdeveloped six (6) specialty
manuals for freestanding ambulatory surgery centers (ASCs)as well
as comprehensive manuals for the following ambulatory payment
classification(APC) training programs:
Basic CPT Outpatient Coding Clinic: This 6.5 hour program is
designed for(Future/Beginning/Current) Coding Specialists, Coding
Managers, ReimbursementSpecialists, Compliance Auditors,
Hospital-Based Clinic Managers, and ALL hospitalstaff responsible
for outpatient coding including emergency room, ancillary
departmentand hospital-based clinic staff. The contents include
general guidelines, steps for coding,and official CPT guidelines
for surgical procedures that are commonly performed in thehospital
outpatient setting. Exercises based on actual ambulatory surgery
operativereports will be used to strengthen the attendees’
understanding of the guidelinespresented.
APC Institute: Impact on Emergency Services: This 3 hour program
is designed forEmergency Department: Directors, Managers,
Supervisors, and Nurses; RegistrationStaff, Health Information
Managers, Coding Specialists, and Cast Room Technicians.The
contents include APC Grouping Logic, Mapping Logic for ED Medical
Visits,APCs for Emergency Department Services, Modifiers –25 and
–27, Emergency Screeningwithout Treatment, Critical Care,
“Clotbuster” Drugs, Tissue Adhesive Wound Closure,and Documentation
Guidelines.
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APC Institute: Outpatient Compliance Action Plan: This 6.5 hour
program isdesigned for Compliance Department Staff (Corporate
Officers, Directors, Managers,Analysts, Auditors); Health
Information Management Staff (Directors,
CodingManagers/Supervisors, Coding Specialists); Risk Managers, APC
Coordinators,Reimbursement Specialists, Decision Support Analysts,
Outpatient Billing Supervisors,Outpatient Billing Specialists,
Software Vendor Product Managers, ALL staff responsiblefor facility
component outpatient coding in: Registration, Hospital-Based
Clinics,Ancillary Departments, and the Emergency Department. The
contents include: BriefOverview of APCs; CPT Surgery Coding
Compliance; and APC Compliance Issues: site-of-service billing,
reason for visits, discontinued surgery, medical visits, “limited
follow-up services,” colorectal cancer screening, observation stay
without recovery, criticalcare, interventional radiology,
modifiers, unlisted procedure codes, units of service, UB-92 claims
data, and higher level APC groups.
APC Institute: Clinical Documentation Strategies: This 6.5 hour
program isdesigned for nursing, utilization management, case
management, and other health careprofessionals responsible for
health records documentation. The contents includeambulatory
payment classification (APC)-related clinical documentation
requirements andmanagement tips for the following sites of service:
Emergency Room, ObservationBeds/Unit, Ambulatory Surgery,
Hospital-Based Outpatient Departments/Clinics, PainManagement
Clinic, Series/Recurring Services, Partial Hospitalization Program,
CastRoom, Ancillary Testing Areas, and Utilization Management.
APC Institute: Coding Guidelines for Hospitals - This 1 or 2 day
program is designedfor all technical, clinical and managerial staff
responsible for facility component outpatientcoding that will
directly impact ambulatory payment classification (APC)
payments.The contents include: Ambulatory Surgery Reimbursement
under APCs, APC DataReporting Requirements, Medicare Hospital
Outpatient Edits, Outpatient BillingProcedures and Guidelines,
Ambulatory Claims Rejection Monitors, Peer ReviewAmbulatory Surgery
Review, Coding System Reviews, How to Use ICD-9-CM, How toUse CPT,
and CPT Coding Guidelines By Body System
(Integumentary,Musculoskeletal, Respiratory, Cardiovascular and
Lymphatic, Hemic and Lymphatic,Digestive System, Urinary, Male
Genital, Laparoscopy/Hysteroscopy, Female Genital,Endocrine,
Nervous, Eye and Ocular Adnexa, Auditory).
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Advanced Clinic Podiatry Surgery
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Jones Consulting Services 6
Modifier Clinic: Hospital Outpatient Issues: This 6.5 hour
program is designed forcoding, reimbursement, compliance, billing,
database management, ancillary, and clinicstaff responsible for
modifier programming, reporting, billing, and auditing. The
contentsinclude: Modifier Reporting Requirements, Official Medicare
Guidelines, RecommendedHospital Front-End Modifier Edits,
Electronic/On-Line UB-92 Reporting of Modifiers,Coding and Billing
Aborted/Discontinued Procedures, ICD-9-CM vs. Medicare
CodingGuidelines, Unsuccessful vs. Aborted/Discontinued Procedures,
Documentation ofReduced/Discontinued Procedures, Testing Potential
Coders, Software Encoder ModifierEdits, Interventional Radiology
Procedures, Information System Upgrades, Data QualityReview,
Radiology Modifier Reporting Issues, Ancillary Department Modifier
Reportingfor Hospitals, and Exercises/Case Studies.
APC Institute: Hospital Financial and Operational Issues: This
6.5 hour program isdesigned for hospital executives, directors,
chargemaster coordinators,coding/reimbursement staff, and
information system/database managers who willimplement ambulatory
payment classifications (APCs). The contents include:
GeneralOverview of APCs, APC Data Reporting Requirements, APC
Policy Issues, Developinga Plan of Action, Conducting Hospital-Wide
APC Education, and Assessing CurrentOutpatient Operations for:
Overall Hospital, Management Information Systems,Business
Office/Patient Accounts, Health Information Management,
AncillaryDepartments/Chargemaster, Emergency Room, Hospital-Based
Clinics, Hospital-OwnedSatellite Facilities, Hospital-Based
Physician Coding and Billing, and UtilizationManagement.
APC Institute: Billing and Reimbursement Issues. This 6.5 hour
program is designedfor Chief Financial Officers, Vice Presidents of
Finance, Controllers, ChargemasterCoordinators, Database Managers,
Software Vendor Product Managers, CodingManagers, Reimbursement
Specialists, Director of Patient Accounts/Business
Office,Outpatient Billing Supervisor/Coordinator, Outpatient
Billing Specialists. The contentsinclude: Durable Medical Equipment
and Prosthetics, Pre-operative Registration,Outpatient Service “Red
Flags,” Chargemaster/Charge Entry, Claims Preparation,
ClaimsPayment, Tracking and Reviewing Medicare Billing
Guidelines.
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Lolita M. Jones Consulting ServicesFREESTANDING
AMBUALTORY SURGERY CENTERTRAINING PROGRAMS
ASC Clinic: Multi-Specialty Procedures - This 6.5 hour program
is designed forFreestanding ambulatory surgery center (ASC)
Managers (Business, Nurse,Reimbursement), Directors,
Administrators, Coding Supervisors, Coding Specialists, andBillers.
The contents include: Current Freestanding ASC Structure,
ProposedFreestanding ASC Structure, Medicare Coding Requirements,
Medicare BillingRequirements, Coding Ambulatory Surgery, How To Use
CPT When CodingAmbulatory Surgery, and CPT Coding Guidelines By
Body System (Integumentary,Musculoskeletal, Respiratory,
Cardiovascular and Lymphatic, Hemic and Lymphatic,Digestive System,
Urinary, Male Genital, Laparoscopy/Hysteroscopy, Female
Genital,Endocrine, Nervous, Eye and Ocular Adnexa, Auditory).
ASC Clinic: Dermatology & Plastic Surgery - This 6.5 hour
program is designed forall technical, clinical and managerial staff
responsible for facility component freestandingASC coding and
billing. The contents include: exercises based on actual
outpatientoperative reports; and CPT coding guidelines for topics
such as: tissue expander, pedicleflap, pressure ulcer, skin grafts,
nail avulsion and excision, scar revision, burn treatment,lesion
excisions, wound repair, adjacent tissue transfer/rearrangement,
breast surgery, freeflaps with microvascular anastomosis.
ASC Clinic: Eye & Oculoplastic Surgery - This 6.5 hour
program is designed for alltechnical, clinical and managerial staff
responsible for facility component freestandingASC coding and
billing. The contents include: exercises based on actual
outpatientoperative reports; and CPT coding guidelines for topics
such as: cataracts. intraocularlens, keratoplasty, trabeculectomy,
strabismus surgery, punctum plugs, tarsorrhaphy,trichiasis
correction, retinal detachment repair, vitrectomy.
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ASC Clinic: Gastroenterology Procedures- This 6.5 hour program
is designed for alltechnical, clinical and managerial staff
responsible for facility component freestandingASC coding and
billing. The contents include: exercises based on actual
outpatientoperative reports; and CPT coding guidelines for topics
such as: hernia repair, nasogastricintubation, percutaneous
gastrostomy tube, hemorrhoidectomy, abscess/cyst drainage,dental
procedures, covered and noncovered colorectal cancer screening,
gastrointestinalendoscopy, esophageal dilation.
ASC Clinic: Orthopaedic Surgery - This 1 or 2 day program is
designed for alltechnical, clinical and managerial staff
responsible for facility component freestandingASC coding and
billing. The contents include: exercises based on actual
outpatientoperative reports; and CPT coding guidelines for topics
such as: ganglion cyst, jointinjections, decompression fasciotomy,
treatment of fractures/dislocations, skeletalanatomy of the hand
and foot, surgical knee arthroscopy, bunionectomy,
toe-to-handtransfer with microvascular anastomosis.
ASC Clinic: Urology Procedures - This 6.5 hour program is
designed for all technical,clinical and managerial staff
responsible for facility component freestanding ASC codingand
billing. The contents include: exercises based on actual outpatient
operative reports;and CPT coding guidelines for topics such as:
retrograde pyelogram, ureter vs. urethra,urethral dilation,
ureteral stent, urethral stent, Burch
Procedure,vesicourethropexy/urethropexy, urodynamics,
chemotherapy.
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I. Introduction
Podiatry is the specialty that manages diseases and problems of
the feet. Manycoding specialists find it difficult to assign
Physician’s Current ProceduralTerminology (CPT) codes to podiatry
cases. Because so many of the podiatryprocedures are currently
performed in the outpatient setting, it is common for
codingspecialists to be “faced” with podiatry cases on a daily
basis.
In order to strengthen their podiatry CPT coding skills, coding
specialists need to firstunderstand the anatomy of the foot:
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II. Clinical Coder: Skeletal Anatomy of the FootA quality
improvement organization (QIO) reviewer recently observed that
coders “don’tunderstand the feet” and, as a result, encounter
difficulties when they try to codeprocedures performed on the foot.
This coding resource reviews the bones of the foot sothat coders
can better understand related procedures.
Source: Illustration by Ida Dox. From Melloni, June L., et al.
Melloni’s Illustrated Review of HumanAnatomy. Philadelphia: J.B.
Lippincott Co., 1988.
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Bones of the Foot are listed below:
NOTE:•••• The first toe (great toe or hallux) has a: proximal
phalanx and a distal phalanx.
• The 2nd, 3rd, 4th, and 5th toes each have three phalanges:
proximal phalanx,middle phalanx and distal phalanx.
Bone(s)
Phalanx; phalanges(pl.)
Metatarsus; metatarsi(pl.)
Sesamoid(s)
Tarsus; tarsi (pl.)
Location
Toes
Foot
First metatarsal
Foot
Description
The toes of one foot include a total of 14bones, or
phalanges.
Each bone consists of a base, a shaft orbody and a head. The
first toe (great toeor hallux) has a proximal and distalphalanx.
The other toes have threephalanges each: proximal, middle
anddistal.
These five long bones are located betweenthe proximal phalanges
and the distal rowof tarsal bones in the back of the foot.
These two small, ovoid bones are foundon the head of the first
metatarsal bone.They are found embedded within atendon or joint
capsule, principally in thehands and feet.
These seven bones of the posterior half ofthe foot are arranged
in two rows. Thedistal row consists of the medialcuneiform,
intermediate cuneiform, lateralcuneiform, cuboid and navicular;
theproximal row consists of the talus(located at the ankle) and
calcaneus (heelbone).
Terms for procedures frequently performed on the bones of the
feet are defined asfollows:
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Term Definition
Exostectomy Removal of a benign bone tumor (exostosis)—for
example, abunion or hallux valgus
Ostectomy Excision of a bone
Osteoclasis Surgical refracture of a bone in the case of a
malunion of brokenparts
Osteoplasty Reconstruction or repair of a bone
Osteotomy Surgical division or section of a bone
Sequestrectomy Surgical removal of a piece of dead bone
Sources: Melloni, June L., et al. (Review of Human Anatomy); and
Sister Agnes Clare Frenay, ssm,Understanding Medical Terminology,
Sixth Edition. St. Louis: The Catholic Health Association of
theUnited States, 1977.
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Following are examples of CPT codes that reference specific
bones of the feet:
28108 Excision of curettage of bone cyst or benign tumor,
phalanges of foot
28310 Osteotomy, shortening, angular or rotational correction;
proximal phalanx,first toe (separate procedure)
28530 Closed treatment of sesamoid fracture
28304 Osteotomy, tarsal bones other than calcaneus or talus;
28470 Closed treatment of metatarsal fracture; without
manipulation, each
Anatomical Reference Points
Each phalanx, metatarsal, and tarsal bone consists of a:
• base (also called proximal end)
• a shaft or body and,
• a head (also called distal end).
Some CPT code descriptions specifically reference these
anatomical reference points,such as:
28111 Ostectomy, complete excision; first metatarsal head
28126 Resection, partial or complete, phalangeal base, each
toe
28153 Resection, condyle(s), distal end of phalanx, each toe
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Joints can be found in between the bones of the feet:
IP joint: the interphalangeal (IP) joint is located in the great
toe, between the base ofthe distal phalanx and the head of the
proximal phalanx.
DIP joint: the distal interphalangeal (DIP) joint is located in
the 2nd through 5th toes,between the base of a distal phalanx and
the head of a middle phalanx
MTP joint: the metatarsophalangeal (MTP) joint is located in the
1st through 5th toes,between the base of a proximal phalanx and the
head of a metatarsal.
PIP joint: the proximal interphalangeal (PIP) joint is located
in the 2nd through 5th toes,between the base of a middle phalanx
and the head of a proximal phalanx.
Tarsometatarsal joint: the tarsometatarsal joint is located
between the base of a metatarsaland the head of a tarsal bone.
Intertarsal joint: a joint that is located between two tarsal
bones.
Many CPT codes specifically reference the joint involved for the
podiatry procedures,such as:
28050 Arthrotomy with biopsy; intertarsal or tarsometatarsal
joint
28289 Hallux rigidus correction with cheilectomy, debridement
and capsularrelease of the first metatarsophalangeal joint
28755 Arthrodesis, great toe; interphalangeal joint
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III. Toe Modifiers
When coding, modifiers provide the means by which the reporting
healthcare provider canindicate that a service or procedure that
has been performed has been altered by somespecific circumstance
(e.g., a procedure performed on the left second toe). In
theHealthcare Common Procedure Coding System (HCPCS) Level II
codes, there aremodifiers specifically for the left side (-LT) and
right side (-RT) of the body. In addition,there are specific
modifiers for each toe:
-TA Left foot, great toe-T1 Left foot, second digit-T2 Left
foot, third digit-T3 Left foot, fourth digit-T4 Left foot, fifth
digit-T5 Right foot, great toe-T6 Right foot, second digit-T7 Right
foot, third digit-T8 Right foot, fourth digit-T9 Right foot, fifth
digit.
When applicable, the modifier is appended to the CPT code which
described theprocedure performed on the toe. For example, has a
repair of their left secondhammertoe, this would be coded and
modified as:
28285-T1 Correction, hammertoe (eg, interphalangeal fusion,
partial or totalphalangectomy) – Left foot second digit
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IV. CPT Coding Tips
Below are some quick tips to keep in mind when coding podiatry
cases:
• Within a single operative report the surgeon may refer to the
sameanatomical reference point using synonyms (for example, the
surgeon may useboth “base” and “proximal end” within the same
report, and both terms aresynonymous with one another);
• Don’t use toe modifiers –TA through –T9 with metatarsal CPT
codes, sincethe metatarsal bones are bones of the midfoot, they are
not located in thetoes/phalanges.
• Remember to repeat the code if it’s description states “each
toe” and theprocedure was performed on multiple toes.
• There is no CPT code for arthroplasty of the toe; use unlisted
procedure code28899. Do not assign codes 26535 or 26536 as they
classify an arthroplastyof the interphalangeal joint of the finger.
Please note that an arthroplasty mayin fact be a hammertoe repair
(see code 28285 if appropriate).
28285 Correction, hammertoe (eg, interphalangeal fusion, partial
or total phalangectomy)
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V. Case Studies
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Case Study # 1. Please assign the CPT code(s)-modifier(s) for
this case:____________________________________________.
OPERATIVE REPORT
Pre-Operative Diagnosis: Morton’s neuroma right foot fourth web
space.
Post-Operative diagnosis: Morton’s neuroma right foot fourth web
space.
Procedure Performed: Resection Morton’s neuroma.
Drains: None.
Estimated blood loss: None.
Specimen: Morton’s neuroma sent to Pathology.
Procedure: With the patient in the supine position after the
usual prep an drape, undersedation with supplemented by local
injection and tourniquet control with 300 mmHgafter proper
exsanguination of the foot, an incision was made directly over the
fourthweb space at the area of the metatarsal heads. This was then
carried down throughsubcutaneous tissue. All bleeders were clamped
and electrocauterized. The incision wascarried down to the tissue
between the metatarsal head and the plantar surface where
theintermetatarsal ligament was seen. It was preserved and not
transected. Directly beneaththe ligament was found a stem of the
Morton’s neuroma. It was grasped, traction wasapplied, and the
neuroma was then brought into the field. It was resected from both
thefourth toe medial side and the third toe lateral side insertions
so the entire neuroma wasthen held by the proximal portion of
nerve. Traction was placed on this nerve and alarge section of the
nerve was removed with the neuroma allowing the proximalportion to
retract up into the midfoot area. When this was completed, the area
wasirrigated and aspirated and the usual closure was carried out
using #3-0 nylon to the skininterrupted sutures. The patient had a
pressure dressing applied and left the operatingroom in good
condition after the application of a hard soled shoe.
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Case Study # 1 continued
Department of Pathology
SURGICAL PATHOLOGY REPORT
DOB: (Age 74)Sex: F
Pathologic Diagnosis:
MORTON’S NEUROMA THIRD & FOURTH TOE RT FOOT: Fragments of
Skeletal Muscle and Synovial Tissue.
Nature of Specimen:MORTON’S NEUROMA THIRD & FOURTH TOE RT
FOOT
Gross Description:
The specimen is received in formalin and consists of an
elongated piece of tantendinous tissue measuring 1.5 cm in length
and 0.2 cm in width. The specimen is seriallysectioned and entirely
submitted. One cassette.
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Case Study # 2. Please assign the CPT code(s)-modifier(s)for
this case: ____________________________________________.
OPERATIVE REPORT
PREOP DIAGNOSIS: Large bony spur, lateral aspect, left foot.
POSTOP DIAGNOSIS: Large bony spur off cuboid bone, left
foot.
PROCEDURE: Removal of bony spur from left lateral foot, cuboid
bone.
The patient was given a general anesthetic agent, he was in
supine position on the tableand prep and drape of the left ankle
and foot was done and a tourniquet was inflated. Aslightly curved
incision was made over the prominence of the bony hump. This was
rightunderneath the short extensor muscle mass of the foot. It
seemed to be more over thecuboid bone area. There was a large bony
spur here that was quite large. All softtissues were stripped off
dorsally and volar ward. Then an osteotome and a ronguerwere used
to smooth out all the bony areas in the base of this spur. After
this wasdone irrigation was carried out. 2-0 Vicryl was used to
close the muscle belly and fasciaand then the skin was closed with
3-0 nylon. Sterile bandage with a little compressionwas applied.
Circulation returned promptly with tourniquet removal. The
patientreturned to the recovery room in good condition. One gram of
Monocid antibiotic wasgiven IV during the procedure.
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Case Study # 3. Please assign the CPT code(s)-modifier(s)for
this case: ____________________________________________.
OPERATIVE REPORTPREOPERATIVE DIAGNOSIS: 1. Hallux limitus, left
first MPJ. 2. Degenerative joint disease, first MPJ.POSTOPERATIVE
DIAGNOSIS: Same.OPERATION PERFORMED: 1. Cheilectomy, left first
MPJ. 2. Subchondral drilling.ANESTHESIA: 1% Xylocaine plain and
0.25% Marcaine plan in ray block fashion.COMPLICATIONS:
None.SPECIMEN: Bone and soft tissue.
PROCEDURE: The patient was seen. The chart was reviewed. The
patient wasbrought back to the OR and placed in the classical
Recumbant position. After achievingadequate IV sedation, the local
mixture was infiltrated as stated. Pneumatic ankle cuffwas placed
on the left side, but not inflated at this time. The patient was
prepped anddraped in the usual sterile fashion. The left foot was
exsanguinated with an Esmarch andthe tourniquet was inflated to 250
mm of mercury. Attention was directed to the leftfirst MPJ, where a
4 cm curvilinear incision was made. The extensor tendon
wasidentified and retracted laterally. The capsule was identified.
Linear capsulotomy wasplaced. The head and base of the left first
MPJ were freed from capsular attachments.Upon doing so, there was a
prominence laterally, dorsally and medially. There was afocal area
of degenerative change in the midportion of the metatarsal head
cartilaginousarea, along with a corresponding area of bony
overgrowth of the base of the proximalphalanx dorsally. Sagittal
saw was used to remove all bony prominence. Ronguerwas used to
remove bony prominence at the base of the proximal phalanx.
Areaswere flushed with copious amounts of normal saline. A 0.45
K-wire was used tosubchondrally drill the area of cartilaginous
deficit on the first metatarsal head.Four holes were placed in and
surrounding the area. Noted, was that there was bonemarrow
protruding, indicated adequate depth of drilling. The area was
flushed withcopious amounts of normal saline. The capsule was
approximated using 3-0 Vicryl.The subcutaneous was reapproximated
with 3-0 Vicryl. The skin was approximated with4-0 Nylon.
Steri-Strip applied. Xeroform was mildly compressive dressing was
applied.The patient tolerated the procedure well without any
complications. Vascular statusreturned to normal levels. The
patient returned to the recovery room in stable andapparent
satisfactory condition. The patient was given postoperative
instruction andprescription for pain meds.
Case Study # 4. Please assign the CPT code(s)-modifier(s)
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for this case: ____________________________________________.
OPERATIVE REPORTPREOPERATIVE DIAGNOSIS1. Hallux rigidus with
degenerative joint disease, first metatarsophalangeal joint, right
foot.2. Exostosis with bursitis, fifth metatarsophalangeal joint,
right foot.
POSTOPERATIVE DIAGNOSIS1. Hallux rigidus with degenerative joint
disease, first metarsophalangeal joint, right foot.2. Exostosis
with bursitis, fifth metatarsophalangeal joint, right foot.
OPERATION1. Cheilectomy with first metatarsophalangeal joint
titanium hemi-implant, right foot.2. Exostectomy and bursectomy,
fifth metatarsophangeal joint, right foot, with drainage of gouty
tophus.
ANESTHESIAIntravenous sedation with local consisting of a total
of 22 cc of 0.5% plain Marcaine.
HEMOSTASISPneumatic ankle tourniquet, right ankle, inflated to
250 mmHg for a total of 66 minutes.
COMPLICATIONSNone.
ESTIMATED BLOOD LOSSLess than 5 cc.
MATERIALSize 3 titanium hemi-implant.
INJECTABLES1. Intravenous Ancef, 1 gm, preoperatively.2. Local
infiltration of 1 cc Decadron (4 mg), postoperatively.
SPECIMENSNone.
Case Study # 4 continued
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Jones Consulting Services 23
PROCEDURE:72 year old male was identified in the preoperative
holding area and was taken to theoperating room. He was placed on
the operating room table in the supine position. Afterobtaining
intravenous sedation, the right foot was locally infiltrated with a
total of 20 ccof 0.5% plain Marcaine. The right foot was then
prepped and draped in the usual sterilefashion. After elevation and
exsanguination of the right lower extremity, the tourniquetwas
elevated to 250 mmHg.
Attention was then directed to the dorsal aspect of the right
foot over the firstmetatarsophalangeal joint. A linear incision was
made, approximately 6 cm in length,and carried down through the
skin and subcutaneous tissue with sharp and bluntdissection. The
vital neurovascular structures were avoided during the dissection
andhemostasis was maintained with electrocautery. The extensor
tendon was identified andlaterally retracted. A linear incision was
then made in the joint capsule and periosteum,exposing the first
metarsophalangeal joint and distal metatarsal shaft.
At that time, there was noted to be significant erosions and
degenerative changes of thefirst metatarsophalangeal joint,
including the metatarsal head. A sagittal saw was usedto remove the
degenerative bone and hypertrophic bone from the dorsal, lateraland
medial aspects of the bone. A rongeur and hand rasp were used to
provide asmooth contour and normal anatomic shape. The sagittal saw
was again used to resectthe base of the proximal phalanx for
placement of the implant.
A size 3 implant was determined to be needed and the size 3
broach was then used to coreout the medullary canal at the base of
the proximal phalanx. The sizer was placed andthis was noted to be
adequate. This was then removed followed by a total irrigation
ofthe wound and placement of the size 3 titanium hemi-implant.
There was noted tobe a good, smooth range of motion at that time.
The head of the first metatarsal wasthen fenestrated with a 0.45
Kirschner wire.
The capsule was debrided and redundant capsule was excised. This
was thenrepaired using 4-0 Vicryl suture in a running fashion. The
subcutaneous tissues were thenclosed and reapproximated using 4-0
Vicryl sutures in a simple interrupted fashion. Theskin was then
reapproximated using 4-0 nylon in a running horizontal mattress
fashion.
Attention was then directed to the dorsal lateral aspect of the
fifthmetatarsophalangeal joint. There, a linear incision was made
approximately 4 cm inlength. Sharp and blunt dissection was carried
out, again avoiding all vital neurovascularstructures and
maintaining hemostasis with electrocautery. The capsule was
incised.At that time, significant inflammatory fluid and gouty
tophus were expressed from thejoint. The capsule and periosteum
were incised throughout the length of the incision,exposing the
fifth metatarsal head. An exostosis was noted and resected with
therongeur. A hand rasp was used to provide a smooth contour to the
fifth metatarsal head.
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Case Study # 4 continued
The joint capsule was also debrided and the bursa was excised.
All gouty tophuswas removed. The wound was flushed with sterile
saline. The capsule was then closedusing 4-0 Vicryl sutures. The
subcutaneous tissues were also closed using 4-0 Vicrylsutures. The
skin was closed with 4-0 nylon sutures in a running horizontal
fashion.
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Case Study # 5. Please assign the CPT code(s)-modifier(s)for
this case: ____________________________________________.
OPERATIVE REPORT
PREOPERATIVE DIAGNOSIS: CONTRACTED FLEXOR TENDONS THIRD AND
FOURTH TOES RIGHT FOOT.
POSTOPERATIVE DIAGNOSIS: CONTRACTED FLEXOR TENDONS THIRD AND
FOURTH TOES RIGHT FOOT.
OPERATION: FLEXOR TENOTOMY AND CAPSULOTOMY THIRD AND FOURTH TOES
RIGHT FOOT.
ANESTHESIA: LOCAL REGIONAL BLOCKADE.
PATHOLOGY: NO SPECIMENS SUBMITTED.
HEMOSTASIS: NONE.
ESTIMATED BLOOD LOSS: MINIMAL.
MATERIALS: NONE.
INJECTABLES: NONE.
COMPLICATIONS:
OPERATIVE PROCEDURE: The patient was brought into the operating
room andplaced on the operating table in the supine position. Local
anesthesia was obtained to thethird and fourth toes of the right
foot using 5 cc of 0.5% Marcaine plain. The right footwas then
scrubbed, prepped, and draped in the usual sterile manner.
Attention was then directed to the third toe of the right foot,
where a 0.5 cm transverseincision was made at the plantar crease
with a #15 blade. Dissection was carried downto the contracted
flexor tendons at the proximal interphalangeal joint. The tendonwas
identified and incised. Attention was then directed to the distal
interphalangealjoint, through the same incision to identify
contracted flexor tendons and jointcapsule structures. Contracted
structures were incised in a transverse manner andstretched. Flexor
contracture deformity was released and the digit was able to be
held in arectus position.
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Case Study # 5 continued
Attention was then directed to the fourth digit of the right
foot, where a transverseincision was made along the plantar flexor
crease at the proximal interphalangeal jointwith a #15 blade.
Dissection was then carried down to the contracted flexor tendons
atthe proximal interphalangeal joint, where the flexor tendon and
contracted jointstructures were incised transversely releasing a
flexor contracture. The incision wasdeepened distally to release
the contracted structures at the distal interphalangealjoint,
allowing the fourth toe to maintain a rectus position. Steri-Strips
were applieddorsally to maintain the third and fourth toes in a
rectus position. Plantar structures werecovered with adaptic soaked
Betadine and gauze.
The patient tolerated the above procedures and anesthesia well
and left the operatingroom with vital stable and neurovascular
structure of the toes intact. Following a periodof postoperative
monitoring the patient was discharged home under her
ownrecognizance. Postoperative instructions were given to the
patient and the patient wasinstructed to make a follow-up
appointment for Tuesday April 8.
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Case Study # 6_. Please assign the CPT code(s)-modifier(s)for
this case: ____________________________________________.
OPERATIVE REPORT
PREOPERATIVE DIAGNOSIS: Ischemic necrosis to the second toe of
the left foot.
POSTOPERATIVE DIAGNOSIS: Ischemic necrosis to the second toe of
the left foot.
ANESTHESIA: 1% local Xylocaine.
OPERATIVE PROCEDURE: Amputation of the second toe to the left
foot.
The patient was placed in a supine position on the operating
room table. Successful localanesthesia was affected with 1%
Xylocaine at the base of the second toe. The toe wasobviously
necrotic. A curvilinear incision was made from the dorsal to
plantar in the firstwebspace around the second toe. The second toe
was disarticulated from itsarticulation at the metatarsophalangeal
joint. The bed of the toe was then fairlyirrigated; then closure
was carried out. The subcutaneous dead space was closed using
2-0Vicryl and the skin closed using 4-0 nylon. There was ample
bleeding during theoperation to be optimistic about the viability
of the amputation site. The foot wasdressed in the sterile dressing
and the patient returned to the recovery room in
stablecondition.
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Case Study # 6 continued
SURGICAL PATHOLOGY REPORT
DOB: (Age 68)Gender: F
Specimen(s) ReceivedA: left 2nd toe
Final DiagnosisGANGRENE LEFT SECOND TOE: Gangrene of skin and
subcutaneous tissue.
*** Electronically Signed Out
Clinical History
Gangrene left 2nd toe
Gross DescriptionThe specimen is labeled “left second toe.”
The specimen is received in formalin and consists of a single
toe measuring 5.0 cm fromthe tip of the toe to the proximal margin.
The toe is covered by darkly pigmented skin.The soft tissue at the
margin is grossly necrotic. A necrotic area is located at the
ventralaspect of the toe. Bone is submitted following
decalcification. Representative sectionsare submitted.Multiple
sections/3 cassettesRepresentative section submitted/hrm.
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Case Study # 7. Please assign the CPT code(s)-modifier(s)for
this case: ____________________________________________.
OPERATIVE REPORT
ASSISTANTNone.
PREOPERATIVE DIAGNOSISOsteomyelitis, right great toe.
POSTOPERATIVE DIAGNOSISOsteomyelitis, right great toe.
OPERATIONAmputation of the right great toe.
ANESTHESIAMonitored.
INDICATIONS:This 70-year-old white male developed chronic
osteomyelitis of the right great toe whichhas not improved with
medical care.
PROCEDURE/FINDINGSUnder intravenous sedation, a right ankle
block was instilled with 1% Xylocaine and0.25% Marcaine. The right
foot and ankle were prepped and draped in the usual fashion.The
tourniquet was applied to the right ankle. The tourniquet was
inflated to 250 mmHg.A standard fish-mouth incision was made at the
level of the interphalangeal joint.The necrotic portion of the
great toe was resected. The toe was disarticulated at
theinterphalangeal joint. The condyles of the proximal phalanx were
then resectedwith a rongeur. Bleeding was controlled with
electrocautery. The wound was closedloosely with interrupted #3-0
nylon sutures. Sterile dressings were applied.The patient tolerated
the procedure well and was taken to the recovery room
insatisfactory condition.
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Case Study # 8. Please assign the CPT code(s)-modifier(s)for
this case: ____________________________________________.
OPERATIVE REPORT
PREOPERATIVE DIAGNOSISHammer toe, fifth toe, right.
POSTOPERATIVE DIAGNOSISHammer toe, fifth toe, right.
OPERATIONArthroplasty, fifth toe, right foot.
INDICATIONS: There was noted to be a focal dermal excrescence
overlying the head ofthe proximal phalanx and lateral aspect of the
middle phalanx over the right fifth toe.Thus, the following
procedure was performed.
PROCEDURE/FINDINGS: On July 23, 2002, the patient was moved from
thepreoperative holding room to the operating room and placed on
the operating table insupine position. Following induction of a
local anesthesia, the right foot was preppedand draped in the usual
sterile manner. The foot was then elevated to 60 degrees abovethe
horizontal for purpose of exsanguination. An Esmarch dressing was
wrapped tightlyabout the foot, the cuff was inflated to 250 mmHg,
and the foot was lowered to theoperating table. The Esmarch
dressing was removed. The following procedure wasperformed:
Arthroplasty, fifth toe, right foot.
Attention was directed to the fifth toe where there was noted to
be a focal dermalexcrescence over the dorsal lateral aspect of the
fifth toe. Thus a 2.5 cm dorsal linearincision was made overlying
the digit. The incision was deepened through sharp andblunt
dissection. With attention being paid to all bleeders, which were
cut, clamped,Bovied, and ligated as necessary. All vital structures
were undermined, underscored, andthen were retracted medially and
laterally for purpose of preservation, revealing theextensor
digitorum longus tendon to the fifth toe, which was transected
transversely atthe level of the proximal interphalangeal joint. The
tendon and capsule were elevatedfrom their underlying osseous
attachments, revealing the proximal phalangeal head. Itwas
transected at the level of the surgical neck and extirpated from
the wound intoto. All osseous prominences were rasped smooth at
this time. The wound was flushedcopiously with sterile saline
solution. Dissection was then carried over the lateral aspectof the
middle phalanx. Utilizing a double-action bone-cutting forceps, the
lateralaspect of the phalanx was transected longitudinally and
extirpated from the woundin toto.
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The wound was washed copiously with sterile saline solution.
There was noted to be noosseous or soft tissue debris within the
wound, and no rough edges remaining.Case Study # 8 continued
With the digit being held in the corrected position, the tendon
was coapted andmaintained, utilizing 4-0 Vicryl with simple
interrupted technique. The skin wascoapted and maintained utilizing
5-0 monofilament nylon with horizontal mattresstechnique. Then 0.25
cc of dexamethasone phosphate and 2 cc of 0.5% Marcaine
wereinstilled through the surgical site. The foot was dressed with
4 x 4, Kling, and Coban, andthen the pneumatic ankle tourniquet was
released. An instantaneous capillary refill wasnoted.
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Case Study # 8 continued
Pathology Report
Age/Sex: 23/F Location: AMB
PREOPERATIVE DIAGNOSISHammertoe 5th right toe
OPERATION PERFORMEDRight Arthrodesis Toe
TISSUE REMOVEDA. Bone, right 5th toe
GROSS DESCRIPTION
RECEIVED LABELED BONE, RIGHT SMALL TOE, ARE TWO PIECES OF
PALEWHITE TO PINK, BONY FRAGMENT MEASURING 1.0 X 0.6 X 0.5 CM AND
0.5X 0.4 X 0.4 CM RESPECTIVELY. ALL BLOCKED FOR
DECALCIFICATION.
PATH PROCEDURES
PROCEDURES: PATH DSM, DECALCIFICATION, A1 BLK, DEC
FINAL DIAGNOSIS
RIGHT 5TH TOE: FRAGMENTS OF BONE WITH MILD DEGENERATIVECHANGE
CONSISTENT WITH HAMMER TOE REPAIR.
Signed ____________________ (signature on file)
________________________
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Case Study # 9. Please assign the CPT code(s)-modifier(s)for
this case: ____________________________________________.
OPERATIVE REPORT
PREOPERATIVE DIAGNOSIS: Hammertoe deformity, left second and
third digit.
POSTOPERATIVE DIAGNOSIS: Same.
OPERATION PERFORMED: Hammertoe deformity correction, left second
and third digits.
ANESTHESIA: Local IV sedation. 1% Xylocaine plain and 0.25%
Marcaine plain in a digital block fashion
SPECIMENS: Bone and soft tissue.
COMPLICATIONS: None.
PROCEDURE: The patient was seen, the chart was reviewed and
thepatient was brought to the OR and placed in the classical
Recumbant position. Afterachieving adequate IV sedation, local
mixture was infiltrated. Attention was directed tothe left foot
after being prepped and draped in the usual sterile fashion.
Attention wasthen directed to the left second and third digit,
where arthroplasty was carried out.0.045 K-wire was placed in a
retrograde fashion and held the digits in place. Areaswere flushed
with copious amounts of normal saline. Vascular status remained
normal.The skin was reapproximated using 4-0 Nylon. Mildly
compressive gauze dressing wasapplied. The patient was given
postoperative instruction. The patient tolerated theprocedure well
without any complications and will be followed up in our
office.
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Case Study # 9 continued
SURGICAL PATHOLOGY REPORT
Sex: F
DIAGNOSIS:A. “Bone, Third Digit Left Foot”: Specimen consistent
with bone removed from a left foot deformity (gross diagnosis).B.
“Bone, Second Digit Left Foot”: Specimen consistent with bone
removed from a left foot deformity (gross diagnosis).
Clinical Information Provided:Painful hammertoe left foot,
second and third digits.
Specimens Received: Gross DescriptionA. Received in formalin and
labeled “Bone third digit left foot” is one roughly saddle-
shaped fragment of gray-tan osseous tissue measuring 1.0 x 0.6 x
0.5 cm. Nohistologic sections are obtained; gross diagnosis
only.
B. Received in formalin and labeled “Bone second digit, left
foot” are two irregularfragments of gray-tan to yellow osseous
tissue measuring in aggregate 1.5 x 1.4 x 0.5cm. No histologic
sections are obtained; gross diagnosis only.
Electronic Signature
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Jones Consulting Services 35
Case Study # 10. Please assign the CPT code(s)-modifier(s)for
this case: ____________________________________________.
OPERATIVE REPORT
PREOPERATIVE DIAGNOSIS: 1. HAMMER DIGIT SYNDROME SECOND DIGIT,
THIRD DIGIT, FOURTH DIGIT, AND FIFTH DIGIT, LEFT FOOT. 2. HAMMER
DIGIT SYNDROME SECOND
DIGIT, THIRD DIGIT, FOURTH DIGIT, AND FIFTH DIGIT, RIGHT
FOOT.
POSTOPERATIVE DIAGNOSIS: 1. HAMMER DIGIT SYNDROME SECOND DIGIT,
THIRD DIGIT, FOURTH DIGIT, AND FIFTH DIGIT, LEFT FOOT.
2. HAMMER DIGIT SYNDROME SECOND DIGIT, THIRD DIGIT, FOURTH
DIGIT, AND FIFTH DIGIT, RIGHT FOOT.
OPERATION: 1. ARTHROPLASTY SECOND DIGIT, THIRD DIGIT, FOURTH
DIGIT, AND FIFTH DIGIT LEFT FOOT. 2. ARTHROPLASTY SECOND DIGIT,
THIRD DIGIT, FOURTH DIGIT, AND FIFTH DIGIT, AND FIFTH DIGIT
RIGHT FOOT.
ANESTHESIA: LOCAL WITH MONITORED ANESTHESIA CARE.
HEMOSTASIS: PNEUMATIC ANKLE TOURNIQUETS AT 250 MM/HG.
ESTIMATED BLOOD LOSS: MINIMAL.
PROCEDURE IN DETAIL: Under mild sedation the patient was brought
to theoperating room and placed on the operative table in the
supine position. Pneumatic ankletourniquets were then placed about
both of patient’s ankles. Following IV sedation localanesthesia was
obtained about both the feet utilizing 20 cc of 0.5% Marcaine
plain. Thefeet were scrubbed, prepped, and draped in the aseptic
manner. An Esmarch bandage wasutilized to exsanguinate the
patient’s feet, and a pneumatic ankle tourniquet was theninflated
on both ankles at the same time.
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Case Study # 10 continued
Attention was then directed to the right foot. On the second,
third and fourth digits ofthe right foot two converging 2 cm
semi-elliptical transverse incisions were madeover the dorsal
aspect of the these digits. The incisions were centered over the
distalinterphalangeal and encompassed the dorsal callous present at
the distal interphalangealjoint. The incisions were deepened
through the subcutaneous tissue, with care beingtaken to identify
and retract all vital neural and vascular structures. The ellipses
of skinwere removed in toto utilizing sharp dissection. All
bleeders were cauterized and ligatedas necessary.
At this time a transverse tenotomy and capsulotomy was performed
to the distalinterphalangeal joint of the second, third, and then
fourth digits of the right foot.The head of the middle phalanx was
freed of its capsular and ligamentous attachments.Next utilizing
the bone saw the head of the middle phalanx was resected and
passedfrom the operative site. The wounds were flushed with copious
amounts of sterilenormal saline. The extensor tendon was
re-approximated and coapted utilizing 3-0Vicryl and the skin was
re-approximated and coapted utilizing 5-0 nylon.
Attention was then directed to the fifth digit of the right foot
two converging 2 cmsemi-elliptical transverse incisions were made
over the dorsal aspect of this digit.The incisions were centered
over proximal interphalangeal and encompassed the dorsalcallous
present at the proximal interphalangeal joint. The incisions were
deepenedthrough the subcutaneous tissue, with care being taken to
identify and retract all vitalneural and vascular structures. The
ellipse of skin was removed in toto utilizing sharpdissection. All
bleeders were cauterized and ligated as necessary.
At this time a transverse tenotomy and capsulotomy was performed
to the proximalinterphalangeal joint of the fifth digit of the
right foot. The head of the proximalphalanx was freed of its
capsular and ligamentous attachments. Next, utilizing the bonesaw,
the head of the proximal phalanx was resected and passed from the
operativesite. The wound was flushed with copious amounts of
sterile normal saline. Theextensor tendon was re-approximated and
coapted utilizing 3-0 Vicryl and the skinwas reapproximated and
coapted utilizing 5-0 nylon using simple interrupted
suturetechniques.
Upon completion of the procedure a total of 1.5 cc of
dexamethasone was infiltratedaround the incision sites. The
incisions were dressed with Betadine soaked adaptic andcovered with
sterile compressive dressings consisting of 4 by 4s and Kling.
Thepneumatic tourniquet was deflated and a prompt hyperemic
response was noted to alldigits of the right foot. An Ace wrap and
postoperative shoe were then applied.
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Case Study # 10 continued
Attention was then directed to the second, third and fourth
digits of the left foot.Two converging 2 cm semi-elliptical
transverse incisions were made over the dorsalaspect of the these
digits. The incisions were centered over the distal interphalangeal
andencompassed the dorsal callous present at the distal
interphalangeal joint. The incisionswere deepened through the
subcutaneous tissue, with care being taken to identify andretract
all vital neural and vascular structures. The ellipses of skin were
removed in totoutilizing sharp dissection. All bleeders were
cauterized and ligated as necessary.
At this time a transverse tenotomy and capsulotomy was performed
to the distalinterphalangeal joint of the second, third and then
fourth digits of the left foot.The head of the middle phalanx was
freed of its capsular and ligamentous attachments.Next, utilizing
the bone saw, the head of the middle phalanges was resected
andpassed from the operative site. The wounds were flushed with
copious amounts ofsterile normal saline. The extensor tendon was
re-approximated and coapted utilizing3-0 Vicryl and the skin was
re-approximated and coapted utilizing 5-0 nylon using
simpleinterrupted suture technique.
Attention was then directed to the fifth digit of the left foot.
Two converging 2 cmsemi-elliptical longitudinal incisions were made
over the dorsal aspect of this digit.The incisions were centered
over proximal interphalangeal joint and encompassed thedorsal
callous present at the proximal interphalangeal joint. The
incisions were deepenedthrough the subcutaneous tissue, with care
being taken to identify and retract all vitalneural and vascular
structures. The ellipse of skin was removed in toto utilizing
sharpdissection. All bleeders were cauterized and ligated as
necessary.
At this time, a transverse tenotomy and capsulotomy was
performed to the proximalinterphalangeal joint of the fifth digit
of the left foot. The head of the proximalphalanx was freed of its
capsular and ligamentous attachments. Next, utilizing the bonesaw
the head of the proximal phalanx was resected and passed from the
operativesite. The wound was flushed with copious amounts of
sterile normal saline. Theextensor tendon was re-approximated and
coapted utilizing 3-0 Vicryl and the skinwas reapproximated and
coapted utilizing 5-0 nylon using simple interrupted
suturetechniques.
Upon completion of the procedure, a total of 1.5 cc of
dexamethasone was infiltratedaround the incision sites. The
incisions were dressed with Betadine soaked adaptic andcovered with
sterile compressive dressing consisting of 4 by 4s and Kling. The
pneumatictourniquet was deflated and a prompt hyperemic response
was noted to all digits of theleft foot. An Ace wrap and
postoperative shoe were then applied.
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Case Study # 10 continued
The patient tolerated the procedures and anesthesia well. The
patient was transferred tothe recovery room with vital signs stable
and vascular status intact to all digits of bothfeet. Following a
period of postoperative monitoring the patient was discharged home
onthe following written and oral postoperative instructions.
POSTOPERATIVE INSTRUCTIONS:1. Keep the dressings clean, dry and
intact.2. To avoid excessive ambulation.3. To ice and elevate both
feet when at rest.4. To wear a surgical shoe at all times when
ambulating.5. To contact surgeon for postoperative follow-up care
or if problems may arise.
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Case Study # 11. Please assign the CPT code(s)-modifier(s)for
this case: ____________________________________________.
OPERATIVE REPORT
PREOPERATIVE DIAGNOSIS: 1. Bunion deformity, right foot. 2.
Hammertoedeformity, right second digit.
POSTOPERATIVE DIAGNOSIS: Same.
OPERATION PERFORMED: 1. Osteobunionectomy with long V-arm with 2
screwfixation, right foot. 2. Extensor tenotomy, right second
digit. 3. Flexor tenotomy, rightsecond digit.
ANESTHESIA: Local IV sedation.
Hemostasis with pneumatic ankle cuff at 250 mm of mercury for 90
minutes.
SPECIMEN: Bone and soft tissue.
COMPLICATIONS: None.
PROCEDURE: The patient was seen. The chart was reviewed. The
patient wasbrought back to the OR and placed in the classical
Recumbant position after givingadequate IV sedation. The above
mixture was infiltrated and pneumatic ankle cuff wasplaced on the
right side at the malleolar level, but not inflated. Foot was
prepped anddraped in the usual sterile fashion. Attention was
directed to the right first MPJ, wherea 5 cm curvilinear incision
was placed medial to the extensor longus tendon. Dissectionwas
carried down to the subcutaneous tissue, being careful to avoid all
neurovascularstructures. Extensor brevis tendon was identified and
tenotomized sharply. The firstinterspace dissection was carried
out. Lateral capsulotomy and adductor tenotomy wascarried out.
Dissection was carried to the capsule medially. A linear
capsulotomy wasmade in same plane as the incision. Next, the
capsule was reflected from the firstmetatarsal. Sagittal saw was
used to remove the dorsal osteophyte and also thedorsal medial
prominence of the first metatarsal. Joint was examined to show
thatthere was smooth cartilage present, with some are of yellowish,
fibrous cartilage on thedirect center of the area, but intact.
Next, the V-osteotomy was made with a long dorsalarm, wings
proximal and apex distal at a 60 degree angle through and through.
The long V-arm encompassed approximately one half the shaft of the
first metatarsal. Next, thecapsule fragment was distracted and
displaced medially, approximately 3 to 4 mm andpacked.
Case Study # 11 continued
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Jones Consulting Services 40
Two 0.45 K-wires were placed on the dorsum to hold the osteotomy
in place and two3.0 self-tapping cannulated screws were placed with
appropriate fixation noted. The K-wires were removed after the
remainder of the medial prominence was resected. All areaswere
rasped smooth of any rough edges and the areas were flushed with
copious amountsof normal saline. The medial capsulorraphy was
carried out.
The capsule was reapproximated using 3-0 Vicryl. The skin was
reapproximated using 4-0 Nylon in a horizontal mattress fashion.
Next, the attention was directed to the seconddigit, where an 11
blade was used to perform an extensor tenotomy and capsulotomyon
the dorsum at the second MPJ. On doing so, unloading the foot, it
was noted thatthe digit was held in a rectus position; however,
there was mild plantar flexion noted,and because of this, a
separate procedure of a plantar flexor tenotomy was carriedout.
Upon doing so, the digit did hold in a rectus position. 4-0 Nylon
was used on thedorsal and plantar incision, one each. Steri-Strips
were applied. Mild compressivedressing was applied with Ace wrap.
Vascular status returned to normal after deflatingtourniquet. The
patient tolerated the procedure well without any completion.
Thepatient returned to the recovery room with vital signs stable
and in satisfactory condition.The patient was given postoperative
instructions and pain medication. The patient is tofollow-up in our
office for postoperative care.
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Case Study # 11 continued
SURGICAL PATHOLOGY REPORT
Sex: F
Clinical Information Provided:Bunion deformity and hammer-toe
second digit right foot.
DIAGNOSIS:“Bone Great Toe”: Specimen consistent with bone
removed from a right foot (toe)deformity - gross diagnosis.
Specimens Received: Gross DescriptionReceived in formalin and
labeled - “Bone right great toe” is one flat fragment of pale
whiteosseous tissue measuring 1.5 x 0.7 x 0.2 cm. No histologic
sections are obtained; grossdiagnosis only.
Electronic Signature
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Case Study # 12. Please assign the CPT code(s)-modifier(s)for
this case: ____________________________________________.
OPERATIVE REPORT
PREOPERATIVE DIAGNOSIS: Severe recurrent hallux valgus deformity
of rightforefoot.
POSTOPERATIVE DIAGNOSIS: Severe recurrent hallux valgus
deformity of rightforefoot.
OPERATIVE PROCEDURE: Right hallux MP arthrodesis.
ANESTHESIA: General per Wood/C.R.N.A. with supplemental 0.5%
plain Marcaineankle block per surgeon for postoperative
analgesia.
TOURNIQUET TIME: Slightly over one hour at 300 mmHg.
DRAINS: None.
COMPLICATIONS: None.
IMPRESSION: Percutaneous threaded K-wires.
DESCRIPTION OF PROCEDURE: After satisfactory general anesthesia
wasestablished with the patient supine on the operating room table.
The tourniquet was thenplaced on the right thigh. Ancef 1 gm IV had
been administered. After successfulanesthesia was established, the
right foot and ankle was prepped and draped to a sterilefashion. It
was held elevated for several minutes. The tourniquet was inflated
to 300mmHg.
A dorsal incision was made along the medial border of the
extensor hallicus longus tendon.Full-thickness subperiosteal flaps
were developed off the base of the proximalphalanx and off the
metatarsal head and neck until adequate exposure of the
jointsurfaces was gained. The articular surfaces were then removed
with hand instruments.The subchondral base plate was left in place
on the proximal phalangeal side, butperforated multiple times with
a K-wire. Once adequate bone resection had beengained in order so
as to allow reduction of the deformity, the threaded K-wires
wereplaced on the base of the proximal phalanx out the end of the
toe. The hallux wasthen positioned in proper location for fusion.
The K-wires were passed into themetatarsal head. The bone was quite
friable, but in spite of this, the fixation andappeared to be quite
good. The wires were cut off and capped.
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Case Study # 12 continued
The wounds were irrigated and closure was obtained was obtained
with interrupted 2-0Vicryl and 4-0 nylon for the skin. A 0.5% plain
ankle block was put in place prior toskin closure. The patient was
awakened from anesthesia and taken to the recovery roomin stable
condition. No complications were encountered and counts were
correct.
DISPOSITION: She will be discharged home following recovery from
anesthesia withoffice follow-up next week. She has Tylox, #40, with
no refill, for pain. She should keepthe dressing dry and foot
elevated. She should weight bear on heel only and report anyinterim
problems if they occur.
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Case Study #13. Please assign the CPT code(s)-modifier(s)for
this case: ____________________________________________.
OPERATIVE REPORT
PREOPERATIVE DIAGNOSIS: Ganglion on the left foot and hallux
valgus on the leftfoot.
POSTOPERATIVE DIAGNOSIS: Ganglion on the left foot and hallux
valgus on the leftfoot.
OPERATION: Excision of the ganglion on the left foot and a
simple bunionectomy onthe left foot.
ANESTHESIA: Intravenous sedation.
HEMOSTASIS: The patient had an ankle tourniquet for
hemostasis.
PROCEDURE/FINDINGS: On October 5, 2001, the patient was taken
from thepreoperative holding area to the operating room and placed
on the operating room table inthe supine position. Following the
induction of intravenous sedation and regional localanesthesia, the
left foot was prepped and draped in the usual sterile manner. The
left footwas then elevated 60 degrees from the horizontal plane for
the purpose of preoperativeexsanguination of the limb. During that
three-minute time period of elevation, thepneumatic ankle
tourniquet was applied to a well-padded site just proximal to
bothmalleoli. The pneumatic ankle tourniquet was then elevated to a
level of 250 mmHg forthe purpose of intraoperative hemostasis. The
left lower extremity was then returned tothe operating room table.
The remainder of sterile draping was completed. The
followingprocedure was performed.
EXCISION OF GANGLION ON THE LEFT FOOT: Attention was directed to
theleft foot, where there was a recurrent, non-resolving ganglion
around the firstmetatarsophalangeal joint area of the left foot.
Therefore, at this time, two semi-elliptical incisions were created
over the dorsomedial aspect of the first metatarsal insuch a
fashion to allow for removal of the ulceration in the skin which is
part of theganglionic cyst. That wedge of skin was removed
completely from the surgical site.The incision was then further
carried down to the level of the subcutaneous tissues. Allcoursing
venous tributaries were identified, clamped, cut,
electrocoagulated, and ligated asnecessary. All vital neurovascular
structures were identified, underscored, mobilized, andretracted
from the incision site. This delivered into view a very thick,
well-defined softtissue mass. The edges and periphery of the mass
were identified and resected from
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Case Study # 13 continued
their surrounding tissue. Then that mass was removed completely
from the surgicalsite and sent to pathology for both gross and
microscopic examination. At the conclusionof this procedure,
attention was directed to the first metatarsophalangeal joint area;
andthe following procedure was performed:
SIMPLE BUNIONECTOMY OF THE LEFT FOOT: At this time, the previous
skinincision was carried down to the level of the subcutaneous
tissues, down into the areaof the capsular tissues over the first
metatarsophalangeal joint. At this time, alinear capsulotomy was
performed within the margins of the original skin incision.
Thecapsular and periosteal tissues were then dissected free in one
confluent layer bothmedially and laterally. This delivered into
view, the first metatarsophalangeal joint area.It should be noted
that there was a very large hallux abducto valgus deformity with
aprominent first metatarsal head. The articulating cartilage was no
longer effective. Muchof that had been destroyed. At this time,
utilizing a sagittal saw, an osteotomy wascreated from dorsal to
plantar, distal to proximal, through and through in such a
fashionto remove that prominent bump of bone on the medial aspect
of the firstmetatarsal. It should be noted that the bone was very
soft and osteoporotic. That bonewas released from all remaining
soft tissue attachments and extirpated in toto from thesurgical
site. Attention was then directed to the osteotomized portions of
bone thatwere rasped to a more smooth and even contour. The wound
was flushed withcopious amounts of sterile saline solution, and
attention was directed towards closure.The capsular tissues were
recoapted and maintained utilizing #4-0 Vicryl in a
simpleinterrupted fashion. The subcutaneous tissues were then
recoapted and maintainedutilizing #4-0 Vicryl in a simple
interrupted fashion. The skin structures were thenrecoapted and
maintained utilizing #4-0 nylon in a simple interrupted fashion.
Attentionwas then directed towards bandaging, where Adaptic, 3 x
3’s, 3 x 3 splints, a Kling, aKerlix and an Ace wrap were applied
in a sterile, compressive and corrective fashion. Thepneumatic
ankle tourniquet to the patient’s left foot was rapidly deflated,
and normalinstantaneous capillary fill time was noted to return to
digits one through five of thepatient’s left foot. The patient,
having tolerated the surgery and anesthesia well, withvital signs
stable and afebrile, was then transported from the operating room
to the post-anesthesia recovery room for further monitoring.
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Case Study # 14. Please assign the CPT code(s)-modifier(s)for
this case: ____________________________________________.
OPERATIVE REPORT
PREOPERATIVE DIAGNOSIS:Rheumatoid arthritis with hallux valgus
and sublux, first metatarsophalangeal joint.Rigid hammertoe
deformities of all lesser digits. Chronic metatarsalgia, left
foot.
POSTOPERATIVE DIAGNOSIS:Rheumatoid arthritis with abductovalgus
and subluxation, first metatarsophalangeal joint.Rigid hammertoe
contractures of the lesser digits.
OPERATION: Keller bunionectomy with 0.62 pin fixation, left
foot. Pan-metatarsalhead resection, left foot. Arthrodesis of the
third, fourth and fifth digits, left foot, with0.45 pin
fixation.
ANESTHESIA: IV sedation with local infiltration consisting of a
total of 20 cc of 0.5%Marcaine plain and a local ankle block.
HEMOSTASIS: Left ankle tourniquet at 250 mmHg for a total of 101
minutes.
ESTIMATED BLOOD LOSS: Less than 20 cc.
MATERIALS: A 0.062 K wire and three, 0.045 K wires.
INJECTABLES: 20 cc of 1% Xylocaine plain, intraoperatively.
COMPLICATIONS: None.
PATHOLOGY: Bone and soft tissue specimen.
PROCEDURE/FINDINGS: The patient was identified in the
preoperative holding area,taken to the operating room and placed on
the operating room table in the supineposition. After obtaining IV
sedation, the left foot was anesthetized with a local ankleblock
and the left foot and ankle was then prepped and draped in the
usual sterile fashion.After elevation of the extremity and
exsanguination, the tourniquet was elevated to 250mmHg. Attention
was then directed to the dorsal aspect of the
firstmetatarsophalangeal joint on the left foot, where a dorsal
longitudinal incision wasmade, approximately 6 cm in length.
Chevron blunt dissection was carried avoiding vitalneurovascular
structures and maintaining hemostasis with electrocautery.
Dissection wascarried out down to the level of the first
metatarsophalangeal joint capsule. The extensor
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Case Study # 14 continuedtendon was identified and retracted
laterally. A longitudinal incision was made to thecapsule and along
the periosteum exposing the first metatarsophalangeal
joint.Significant degenerative changes were noted, along with
subluxation of the joint. Sagittalsaw was then used to resect the
base of the proximal phalanx and also partialresection of the head
of the first metatarsal. All bony irregularities were also
removedwith rongeur and remodeled with sagittal saw and hand rasp.
A complete lateralrelease was performed of the joint capsule in
order to facilitate medial reduction ofthe hallux. Attention was
then directed to the dorsal aspect of the thirdmetatarsophalangeal
joint where a longitudinal incision was made approximately 3 cm
inlength, extending to the base of the proximal phalanx. Again,
sharp and blunt dissectionwas carried out avoiding vital
neurovascular structures and maintaining hemostasis
withelectrocautery. Dissection was carried out down to the level of
the metarsophalangealjoint and the capsule was incised. A sagittal
saw was used to resect the head of thethird metatarsal with the cut
being oriented dorsal distal to the plantar proximal.Attention was
then directed to the proximal interphalangeal joint of the third
toewhere a transverse incision was made, approximately 1 cm in
length. Dissection wascarried out to the level of the extensor
tendon, which was then incised, at the level of thejoint, medial
and lateral collateral ligaments were released, exposing the head
of theproximal phalanx. This was resected with a sagittal saw,
obtaining reduction of thehammertoe deformity. The cartilage on the
base of the middle phalanx was then denudedwith sagittal saw and
curette. At that time a 0.045 K-wire was driven in a
retrogradefashion, across the proximal interphalangeal joint and
then driven proximally into the thirdmetatarsal maintaining
reduction of the hammertoe deformity andmetatarsophalangeal joint
contracture. The dorsal incision over the third toe
wasreapproximated with 4-0 nylon in a simple interrupted fashion.
Subcutaneous closurewas performed over the third
metatarsophalangeal joint with a 3-0 Vicryl in a simpleinterrupted
fashion, followed by skin reapproximation with 4-0 nylon. Attention
wasthen directed to the dorsal aspect of the fourth and fifth toe
and metatarsophalangealjoint where the same procedures were then
performed reducing the hammertoecontractor and resecting the fourth
and fifth metatarsal head. Fixation andclosure was performed the
same. At that time, attention was redirected back to
firstmetatarsophalangeal joint, where retrograde fashion a 0.062
K-wire was placedthrough the hallux and then proximally into the
first metatarsal maintainingreduction of the hallux valgus
deformity. Capsular structures were closed using 3-0Vicryl in a
simple interrupted fashion. The skin was then reapproximated with
4-0 nylonin a running horizontal fashion. Prior to closure, all
wounds were irrigated copiously withsterile saline and Bacitracin
solution. No procedure was performed to the
secondmetatarsophalangeal joint or second toe, because this has
been surgically removedin a previous surgery three to four years
ago. All wounds were dressed withAdaptic, 4/4 gauze and bulky
compressive sterile dressing to the entire left foot and ankle.The
tourniquet was released after a total of 101 minutes with
instantaneous perfusion andcapillary refill to the digits on the
left foot.
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Case Study # 14 continued
The patient tolerated the procedure and anesthesia well. She was
taken to recovery withvital signs stable and vascular status intact
to the left foot. She has been givenpostoperative medications for
pain control and instructions for no weightbearing on theleft foot.
She will follow-up in my office in approximately 5-7 days.
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Case Study # 14 continued
PATHOLOGY REPORT
Age/Sex: 78/F Location: AMB
PREOPERATIVE DIAGNOSIS: Rheumatoid foot
OPERATION: Left arthroplasty, arthrodesis foot, pan-metatarsal
head resection foot, Arthroplasty 2-5 foot Arthrodesis
TISSUE REMOVED: A. Bone and soft tissue
GROSS DESCRIPTION: Received labeled bone and soft tissue L foot.
The specimenconsists of three pieces of pearl white to yellow and
pink bony tissue fragment ranging insize from 1.1 - 1.8 cm in
greatest dimensions. All blocked for decalcification.
PATH PROCEDURES: Path DSM, Decalcification, A1 BLK, DEC
FINAL DIAGNOSIS: Bone and soft tissue, right foot, excision:
Benign bone andcartilage with severe degenerative changes present.
A few cartilaginous fragments,consistent with loose bodies, are
identified, but histologic features diagnostic forrheumatoid
arthritis are not identified.
Signed _________________ (Signature on file)
____________________________
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VI. Sample CPT Audit Findings
Below are the written summaries provided to a Hospital after the
author performed aCPT coding review of a sample of their ambulatory
surgery cases in 2002:
Medical Record#: 1Discharge Date: 06/13/02
This Managed Care patient was seen for a second metatarsal
osteotomy and a right fourthdigit arthroplasty, both of which were
coded correctly as 28308 and 28285. However,the Tailor’s
bunionectomy was inappropriately coded as 28296 (Correction of
bunionwith metatarsal osteotomy). Please delete code 28296 and
assign 28110 (Ostectomy,partial excision, fifth metatarsal head).
Per the operative report for this case: “. . . thefifth
metatarsophalangeal joint, where an approximate 4.5-cm linear
incision was thenmade. . . fifth metatarsal . . . exostosis was
resected in toto. . . an Austin-type osteotomywas then
performed.”
A Tailor’s bunionectomy procedure involves a lateral
longitudinal arthrotomy, in whichthe fifth metatarsophalangeal (MP)
joint is exposed. The lateral prominence or exostosisof the
metatarsal head is resected, and the capsule is tightly
imbricated.
Medical Record#: 2Discharge Date: 03/27/02
The Medicare patient was seen for a right hallux
metatarsophalangeal (MP) arthrodesis,which was inappropriately
coded as 28292 (bunion correction). Delete 28292 and assign28750-RT
(Arthrodesis great toe, metatarsophalangeal joint). Per the
operative report: “.. . flaps were developed off the base of the
proximal phalanx and off the metatarsal headand neck. . . bone
resection had been gained in order to allow reduction of the
deformity,the threaded K-wires were placed on the base of the
proximal phalanx out the end of thetoe. . . the K-wires were passed
into the metatarsal head. . . the fixation appeared to bequite
good.”
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Medical Record#: 3Discharge Date: 11/24/02
The Commercial patient was seen for a radical bunionectomy with
osteotomy, which wascorrectly coded as 28296. However, the first
metatarsophalangeal (MTP) jointexostectomy was inappropriately
coded. Please delete code 28288. Per the AmericanAcademy of
Orthopaedic Surgeons (AAOS), code 28296 includes “removal of
additionalexostoses in the area of the joint.”
Medical Record#: 4Discharge Date: 09/09/02
The Medicare patient was seen for bilateral radical bunionectomy
with osteotomy, whichwas coded as a unilateral surgery with code
28296. Please append bilateral proceduremodifier –50 to code 28296.
Per the operative report: “Attention was then directed tothe dorsal
aspect of the left foot, where a procedure identical to that
described for theright foot was performed. . . “
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VII. Case Studies Answer Key
Case Study 128080-RT
Case Study 228104-LT
Case Study 328289-LT
Case Study 428289-RT28899-RT28288-RT
Case Study
528272-T728272-T7-5928272-T828272-T8-5928234-T728234-T7-5928234-T828234-T8-59
Case Study 628820-T1
Case Study 728825-T5
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Case Study 828285-T9
Case Study 928285-T128285-T2
Case Study
1028285-T128285-T228285-T328285-T428285-T628285-T728285-T828285-T9
Case Study 1128285-