Modifier usage, as well as payers' acceptance of modifiers 50, 51, 59 and the toe modifiers discussed in . Currently, once conservative management fails, the mainstay of treatment is debridement and excision-interposition arthroplasty. The cadaveric specimens were utilised as part of specialised foot and ankle training workshops run by the authors; the specimens were obtained through standard procurement processes with all necessary permissions. Response: Sadly, I think this has become the norm as opposed to the unusual. Im not an expert but I wouldnt collect more when you know youll need to refund. First MPJ Arthroplasty. Not only does this code allow for reporting of the hemi- and total arthroplasty implants but basically any other type of implant placed in the joint space such as Cartiva (synthetic cartilage plug) or Arthrosurface Hemi-cap implants which are not joint replacement implants. <> Silicone implant arthroplasty for second metatarsophalangeal joint disorders with and without hallux valgus deformities Foot Ankle . Any suggestions? 1) CPT 28820-Amputation, toe; metatarsophalangeal joint, 2) CPT 28825-Amputation, toe; interphalangeal joint. If not, then you need to bill those visits. A novel implant was designed and developed by the senior author (NPS) (Fig. Total hip replacement for the treatment of severe osteoarthritis. 1989;28(3):1959. The example given is for osteomyelitis, but it is not saying it is the only example; it is just one example. Total knee replacement (arthroplasty) 27447. It can also include fusion of the interphalangeal joint (the location where two phalanges join). The aim of this study is to evaluate this novel replacement arthroplasty of the lesser metatarsophalangeal joint in a laboratory setting and cadaver implantation. Use of the Classic Hemi-Cap toe implant is a resurfacing procedure. PNFF: Participated in the cadaver trials, interpreted the results of the study and participated in the reviewing process. For clinical trials, as with other replacements, the ideal candidate must be sought, followed by the stringent principles of replacements and informed consent. Policy Aetna considers the following procedures medically necessary for persons with disabling arthritis of the first metatarsal phalangeal joint (hallux rigidus): inappropriate to use. Turnaround slowdowns let them keep funds longer but does neither our practices or the patients we serve any justice. All Cadaver parts were donated for research purposes Protocol number M180380 Ref: W-CJ-140813-1 (13-08-2014). Although it is considered to be a three-component implant, the mobile bearing meniscus clips onto the phalangeal component via a peg which is smaller in diameter from the corresponding phalangeal socket allowing for multidirectional gliding at this interface, thus providing both stability and decreasing the torsional forces. The higher co-payments above the approved amount are how the insurance companies pay nothing and have shifted costs to the patients. Most published series stem from the 1970s and 1980s [17,18,19,20,21,22,23,24,25]. How would I code a second metatarsal-phalangeal joint hemi-implant procedure? unless the diagnosis specifically has. Semin Arthroplasty. Surgical arthroscopy of the shoulder, rotator cuff repair. 568 0 obj You have to protect your practice. Myerson MS, Kadakia AR. "Over the last 14 years, our procedure has had a very high success rate," says Joseph . This novel lesser metatarsophalangeal joint replacement arthroplasty has been developed as an option in the surgical treatment of symptomatic degenerative joint disease and/or Freibergs infraction resistant to conservative treatment. I billed CPT 11042 weekly post-operatively, until the wound healed. The only good news about this situation is that the MUE Adjudication Indicator (MAI) is 3. The interpositional arthroplasty procedure in treatment of degenerative arthritis of the second metatarsophalangeal joint. A metatarsophalangeal joint capsulotomy (CPT 28270)may be coded in addition to CPT 28285 per CPT Assistant if it is performed to treat a separate deformity (e.g., a contracture of the MTP joint) 3. Radiographic appearance of the implant (antero-posterior and lateral views). The trial liners are used to determine the size of the plastic bearing meniscus. The fixation is intramedullary (a novel spring fixation system for the metatarsal and a screw fixation for the phalangeal component) and the implant has high conformity and low constraint to withstand the stresses applied on it by walking and weight bearing, thus minimizing wear. CPT 28297. 1992 . And, that in the course of preparing the site for the implant, the 1st metatarsal-phalangeal joint is remodeled with all the excess bone resected - medial, dorsal, and lateral. Although not subjected to large axial loads, these replacements still need to adhere to the basic principles of replacement implants and good soft tissue tension restoration to be successful. https://doi.org/10.1053/j.jfas.2014.12.003. This is an in vitro and cadaver study of a new design replacement arthroplasty developed by the senior author. 2023 CPT Changes for Surgery Now Available - click on Shop to learn more! Our office now has to print the medical claim, attach medical notes, and send the old fashioned way as opposed to sending claims electronically. Knee Surg Sports Traumatol Arthrosc. { While hammertoe repairs are routine procedures for podiatrists, not all operative reports for a hammertoe repair read the same because there are different combinations of surgical procedures that may be required to correct the hammertoe, depending on the severity of the deformity. Many people who have undergone arthroplasty report . Lui TH. Each author certifies that he has no commercial associations that might pose a conflict of interest in connection with the submitted article. Lui TH. hbbd```b``~ "WH&}=&6VifH d The 2nd TMT joint is approximately 1-2 cm proximal to the 1st TMT joint. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. The sizes of the metallic components (metatarsal and phalangeal) were determined by the accurate measurement of the respective bones on skeleton specimens. HV6}WbFH6iKi=DIWF`433gZ_\W/_Wg`O?ZBvVuX}WR O9#)6RK':h. %%EOF interphalangeal fusion, partial or total phalangectomy) L3010 RT KX and L3010 LT KX always got reimbursed until recently. https://doi.org/10.3928/0147-7447-19870101-15. My fee for sending them charts is $50 per chart. The stability was excellent in both dorsal displacement and dorsiflexion. The soft tissue is repaired and once again stability, alignment and range of motion are checked. 1989;1:113. This proof of concept study is the basis for clinical trials. & Strydom, A. The body part is . Methods Four groups of patients were recruited. Following these tests, it was implanted in 15 fresh frozen cadavers at various stages of its development, during which the surgical technique was perfected. Lavery L, Harkless LJTJ. https://doi.org/10.1177/1071100713491728. Finally, it is also appropriate to code CPT 28285 for repair of a claw toe deformity with extensor tenotomy and flexor tendon transfer. . Table2 shows the measurements pre and post endurance testing. K-wire fixation through any joint in the toe undergoing hammertoe repair including the PIP; the DIP; or the metatarsophalangeal (MTP) joint. Eight patients reported good or excellent results [30]. Cyclic loading of the implants under physiological loads has shown no signs of wear or damage. Epidemiology. 2014;13(4):199205. PubMed Townshend DN, Greiss ME. It is the distal-most and major insertion of the plantar fascia (, Click to share on Twitter (Opens in new window), Click to share on Facebook (Opens in new window), Click to share on Google+ (Opens in new window), on Plantar Plate Repair of the Second Metatarsophalangeal Joint, Surgical Repair of Fifth Digit Deformities, Central Rays: V Osteotomy, DFWO, Condylectomy, Lesser Digital Deformities: Etiology, Procedural Selection, and Arthroplasty, Joint Salvage and Preservation Surgical Techniques for Hallux Limitus, McGlamry's Comprehensive Textbook of Foot and Ankle Surgery. This was a small cohort with short follow-up. 10 - Radiographic appearance of the implant (antero-posterior and lateral views)). Article '`n@`:8 3LA0S)d,L3YFa^zWD%vEJgYtV8+JgYtV8+Jgr{ZyuAG|Rh',\_ Besides the one pre-implant specimen which was lax, all the others were stable both pre- and post-implant. Silicone [17,18,19,20,21,22,23,24,25,26], metal [17,18,19,20,21,22,23,24,25,26,27,28,29] and ceramic [30] LMTPJ replacement arthroplasty as well as osteochondral autograft transplantation [6] have been reported with mixed success. Stability and range of motion is checked. 3) The 1135 waivers are in place for a period not less than 151 days after the end of the PHE or through the end of Calendar year 2023 or two years after the end of the PHE. To date there is no effective long-term replacement arthroplasty option. Zgonis T, Jolly GP, Kanuck DM. Other conditions that should be considered, in descending order of frequency, include, but are not limited to, distal metatarsal stress fracture, Frieberg disease/osteonecrosis, systemic/autoimmune arthritis (rheumatoid, psoriatic, etc. Chalayon O, Chertman C, Guss AD, Saltzman CL, Nickisch F, Bachus KN. endstream endobj 595 0 obj <>stream Range of motion and stability was tested using custom made instrumentation in four cadavers. David J. Freedman, DPM, CPC, Silver Spring, MD, RE: Ciox Medical Records Request (Gerald Newman, DPM). Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. 2007;15(5):5559. J Foot Surg. https://doi.org/10.1186/s12891-021-04257-x, DOI: https://doi.org/10.1186/s12891-021-04257-x. Freibergs disease. osteomyelitis or bossing); CPT 28126: Resection, partial or complete, phalangeal base, each toe, CPT 28153: Resection, condyle(s), distal end of phalanx, each toe, CPT 28160: Hemiphalangectomy or interphalangeal joint excision, toe, proximal end of phalanx, each. Response: This is pretty straightforward. The distal end of the plantar plate inserts into the base of the proximal . described a case study using a titanium hemi-implant of the proximal phalanx. Silicone implant arthroplasty for second metatarsophalangeal joint disorders with and without hallux valgus deformities. 2007;17(2):735. Implant arthroplasty of the lesser metatarsophalangeal joint a modified technique. Lesser metatarsophalangeal joint implants. J Foot Surg. Have you been billing E/M providing the patient with an evaluation and medical management post amputation? 4 - Cadaver testing set up). The goals of shortening the metatarsal are to decrease pain at the base of the second toe (in the ball of the . Group1 included 22 feet of 11 healthy controls (age 48.6 . I did surgery on the left foot in November of 2022 and billed CPT 28297 and 28310-XS. 'Yr;\(0Ei(#`a ]pw LUZ[(\p6(p0%i;]Pu This novel LMTPJ replacement arthroplasty has been developed to fill the void of replacement arthroplasty options in the isolated arthritic LMTPJ. There are few cadaveric studies pertaining to general loading and forces on the LMTPJ and there are no available cadaveric studies for LMTPJ replacement arthroplasty. All of the above listed CPT codes have a post-operative global period of 90 days. Excision of the phalanges or fusion of the interphalangeal joints will help the toe to lie flat again and not pop back up after surgery. Eight of nine patients reported good or excellent results at a mean follow-up of 23months [30]. PIP (Proximal Interphalangeal) Joint Fusion. Modification of lesser metatarsophalangeal joint arthroplasty using flexor digitorum longus transfer. The 3rd TMT joint is in line . eazyTi&YuW^IdmfQAU 1M@z@ iRE2,R? David J Freedman, DPM, CPC, Silver Spring, MD. This scenario should be included in your next office meeting agenda and documented in your compliance manual. The authors declare that they have no competing interests. Other potential treatment options include implant arthroplasty, metatarsal head resection, debridement only, and soft tissue interposition. 2009;30(2):16776. Each author personally and significantly contributed towards the development of this article: NPS: Conceived and planned the activities that led to the study, executed the testing and cadaver trials, wrote the paper and approved the final version. Dorsal excursion may elicit pain or guarding as one is performing a Lachman-drawer examination of the MTPJ (, A most helpful test to determine plantar plate insufficiency, even in patients with minimal digital contracture, is to perform, Recognition and diagnosis of the inflamed or ruptured plantar plate has eluded physicians for many decades, as some of the presenting signs and symptoms can be misinterpreted as unrelated entities. 660 0 obj The in vitro cadaveric studies allowed the researchers to develop and perfect the surgical technique, record the range of motion, determine the stability both clinically and by means of applied forces. 2 - Cyclical testing instrumentation four stations). The solution is to fix the problem once and for all and to put an end to abusive payment practices performed by insurance companies. Cyclical testing instrumentation four stations. Podiatry Management 400 Cranberry Ln, West Chester, PA 19380, Copyright 2023, Podiatry Management Online - All Rights Reserved. 1984;23(1):3540. 569 0 obj 26536. >Xq(m]3)Ar Uatd=yE#))=\OE&3KslB)vCF7hH(*pb&E-,J]Bd6RoiIW /.#R:rz$0VBMj\DISSq3G%F d~ oTNfxfDPu@MmHR5yyDw +9gb}ls!ZbDiq!qh6m\B&MS3[ilMX^q *h{RbQg/OcQZP=a8 CQ26^ KDX /xw@55wd-+t"2J}&CA_@r{!/TO:*R ~xsiruuHK(LHY$@ov{ZcS'[ iBIQ/~STtL `/X% fJ#Y Yn(WAqLZ&B }X8G,s%+dd9a4DH~lVx0aZ=8xS3Kw;Ur-aM#M^" 3EgCYOkpC17'[email protected]@sbBmKN/$*,>A>1;4u~IU'xBB)tV0} 4=w7y1C +R&()'(po(7C};B&1L76nn,0S}u':A8c@s((y-Z^|1&HPmB&k&f+90_jWw& [I&[IX^EOS"vEO \px,oGsfCk#KGjY,UG #D4X?}l0L,W6)-kcM6rTJjxy{kM6_988]abZwZVZ.5M8` -SE' {?s I am wondering what other people's opinion is on this. Maybe we should start telling our patients to switch plans to avoid us from charging them what the health plan rejects. Are these ever for pre/post payment claim reviews or only for data mining? Some will present in their senior years having a long-standing untreated bunion and overlapping second toe that simply wont fit into a shoe. Nevertheless, the range of motion was maintained and even slightly improved in some of the specimens. Tell the patient your insurance wont allow me or your insurance wont pay for that? There is a paucity of published information on alternative treatment options as far as arthroplasties are concerned when conservative therapies fail. PubMed Moreover, the contact surfaces of all four titanium implants show no discolouring after 5 million cycles. Post-operative stability was objectively assessed for dorsal displacement and dorsiflexion using a 5kgf (49N) and was found to be excellent. Complete lesser metatarsophalangeal replacement in situ. Joint replacement arthroplasty has been used in the end stages of the disease . z Are HIPAA waivers expired? Freed JB. Sgarlato has advocated the use of a double-stem silicone prosthetic implant in several difficult-to-treat conditions. Is there a modifier for submitting related charges for necessary services? PubMedGoogle Scholar. 1980;19(1):168. Y?3.i(HC_HZlhm"p(PQT!&,0|`P^a ``` @6 QuE@ H+X$y nz?;t8x/l`>}A Michael G. Warshaw, DPM, CPC, Lady Lake, FL. 1) You can bill Medicare for an initial E/M encounter (eg. It depends on the contracts. { Needless to say, I do not send any charts unless the invoice gets paid. This novel three-component implant has high conformance and a large bearing surface. Tintocallis CA. A denial of services due to an MUE is a coding denial, not a medical necessity denial. Foot Ankle Int. We can see from the CPT description that this code includes removal of part or all of a phalanges (the three small bones that join together to form our toes). A patient presented with a left ruptured plantar plate, dorsal contracture with subluxation and ruptured flexor tendons of the second metatarsophalangeal joint. Lesser Metatarsal Metallic Hemiarthroplasty. Fusing the most affected joint or joints is a reliable way to decrease the pain and improve the function of the foot. 3rd metatarsal fractures rarely occur in isolation. Some of their calls even appear on the caller ID as Spam. And then in December of 2022, I did surgery on the other foot and billed it as CPT 28297-79-RT. Mean follow-up was 23months with a mean AOFAS score of 75. During the evolution of the implant design, 15 cadavers were used over a period of 4years. We billed several different attempts with T modifiers for toes, -51 modifier, -59 modifier and -XS modifier. Sgarlato T. A new implant for the metatarsophalangeal joint. 2005;87(9):190910. 5 Hallux disarticulation for application of electro-goniometer). Andrew Strydom. I have never collected more than the fee schedule allowed for the code, so if the co-pay is larger, I dont collect the entire co-pay. Arthrodesis leaves the second MTP joint without any range of motion, and so has the potential to result in altered gait mechanics, transfer metatarsalgia, and adjacent joint degenerative disease. If there is no code available, the only other option is to use the NOC [not otherwise coded] CPT 28999 and submit claim with an operative report, and request peer review for reimbursement consideration. On average the subluxation stability of the intact joints is around 25N in a dorsal or superior direction and approximately 16N in dorsiflexion [32, 33] (Fig. BMC Musculoskelet Disord 22, 424 (2021). Response: There is no CPT code for this procedure. Make sure you use the proper wound code diagnosis. This CPT code has a post-operative global period of 0 days. The joints were stable both pre- and post-operatively. Soft tissue balancing and fibrous tissue surrounding the implant provide the majority of strength to support the joint. Why were you denied in the past? Arthrodesis of an osteoarthritic second metatarsophalangeal (MTP) joint is suboptimal because of altered gait mechanics; hence, joint-preserving procedures are of value. The surgical technique was found to be simple and reproducible in the cadaver trial. If the patient's contract says that the podiatry co-pay is $40, then in my opinion, if the allowed amount is less than $40, the patient still contractually pays $40. Sgarlato TE. In contrast, the three units allow documentation supporting the service's medical necessity. So, what exactly is included in CPT 28285 for a hammertoe repair? https://doi.org/10.1016/j.foot.2006.09.006. Demographics. L Tarsometatarsal Joint, Left M Metatarsal-Phalangeal Joint, Right N Metatarsal-Phalangeal Joint, Left P Toe Phalangeal Joint, Right Q Toe Phalangeal Joint, Left Open 4 Internal Fixation Device 8 Spacer Z No Qualifier Reposition (Moving to its normal location, or other suitable location, all or a portion of a body part. Transfer metatarsalgia was a reported complication in both the reservation and failure groups [17]. I have been told by the experts that I am obligated to collect the entire co-pay even if I know I will have to issue a refund. Pfeiffer WH, Cracchiolo A 3rd, Grace DL, Dorey FJ, Van Dyke E. Double-stem silicone implant arthroplasty of all metatarsophalangeal joints in patients with rheumatoid arthritis. A first MTP joint resection arthroplasty treats arthritis of the big toe. I found very little information relating to Cartiva and Arthrosurface implants but if you review Aetna policy #0661 you will see that toe joint resurfacing is considered experimental/investigational. Toe Amputation CPT Reimbursement. 28899, should be used. Google Scholar. Some insurance companies have their own criteria for authorization, such as only one injection on a date or only one injection in 6 months or other limitations like that. 15 - Wear of contact surfaces post testing after 5,000,000cycles at excessive forces). . Foot Ankle Int. This three-component mobile bearing device is made of titanium and high density polyethylene which evolved over 4years. J Foot Ankle Surg. Philadelphia: Elsevier Saunders; 2005. endstream endobj 603 0 obj <>stream Second Metatarsal Shortening Osteotomy. Three mm of the base of the proximal phalanx is excised using an oscillating saw and the proximal phalanx is hyper plantar flexed. The joint closest to our foot is called the proximal interphalangeal joint (or PIP) while the joint furthest from our foot and closer to the ends of the toes is called the distal interphalangeal joint (or DIP). 1983;22(1):40-44. The plantar condyle is preserved with this implant so that the weight bearing status of the involved metatarsal will be maintained thus avoiding transfer lesions. When we billed these codes, our EMR system and our clearing house rejected the codes. Once the soft tissue is well balanced, the correct size polyethylene is inserted into place (Fig. J Am Podiatr Med Assoc. https://doi.org/10.1016/j.eats.2016.08.008. Unfortunately, an infection developed following the procedure, necessitating an amputation of the hallux to be performed. They know what to expect. So, the avulsion fracture excision from the distal fibula would be properly billed as CPT 27641. https://doi.org/10.1177/1071100718786494. Yes, I win every time, but I have to appeal over and over again. The metallic components are made of titanium with a grid blasted under surface for maximum bony ingrowth. More bone is excised as required in order to maximize range of motion. Left and right arrows move across top level links and expand / close . Does one have to record the video or audio in order for it to be reimbursed or could one just take notes? Paul Cadorette At an average follow-up of 37months, a good subjective result was recorded in 63% and good with reservations in 25%. 7 - Cannulated reamer over the guide wire). The capsule is split longitudinally. HHPXrnbT%%15J#;~|N+U f"FS=Kj? other diagnoses such as. https://doi.org/10.2106/00004623-200509000-00001. Please keep in mind that an arthroplasty could be a hammertoe replacement (see code 28285 if necessary). RE: Aetna Medicare Advantage (Jeffrey Kass, DPM). For my visual learners, check out this image of a hammertoe: Hammertoe. a metatarsal . MAI 3 indicates a value adjudicated by claims processing systems at the date of service level. Plasma spray titanium coating for osseointegration. Stautberg EF III, Klein SE, McCormick JJ, Salter A, Johnson JE. Are there other opinions out there? If the documentation and paperwork does not meet the criteria, they are denying the claim. I fax or email them an invoice and can honestly say I do not think they have ever paid. I would think that this sufficiently meets the "bunion correction" requirement. The benefit of this hemi-implant is that it does not alter the metatarsal parabola and allows for other surgical procedures to be performed in the future [28]. Are we obligated to do them by our payor contracts? . Both have a 0 day global period which means any care after the amputation day is an E/M. Thompson FM, Hamilton WG. Appeals are a waste of time. Degenerative arthritis of the lesser metatarsophalangeal joint (LMTPJ) in the foot is a relatively uncommon condition as compared to the inflammatory arthritides. The implant was found to be durable and resistant to wear in the laboratory testing. Freibergs infraction: a new surgical procedure. This procedure stops pain by preventing the surfaces of the big joint of the big toe from rubbing together. The closure left an area open due to soft tissue deficit. 2012;30(12):19958. 2013;34(10):143642. No polyethylene particles were found in the de-ionized water. By using this website, you agree to our Both dorsal and plantar incisions were made over the second metatarsophalangeal joint. $"j/Fr Studies currently available are between case series and reports at level IV and V. The findings cannot be generalized or interpreted due to the low numbers, the retrospective nature of the studies and due to the rarity of the disease. What is included in the CPT code 28285? Part 2: quantification of the dynamic distribution. ), and gouty or infectious arthritis (, The plantar plate is a fibrocartilagenous, cup-shaped, intraarticular plantar covering of the MTPJ whose superior surface is in direct contact with the metatarsal head. Springer Nature. In consultation with the engineers, the friction and friction losses through the set-up were found to be negligible. HWYoF~%`.01. I am not sure what this means and which code to add the -59 modifier to.. Coleen Merrill, Billing Specialist/Consultant, Southern Oregon Foot & Ankle, LLC, Medford, OR, In this scenario provided, I ran the two codes back and forth and when you compare CPT 28750 to CPT 28285, the column 2 code is CPT 28750; and when you switch by putting in CPT 28285 to CPT 28750 the column 2 code is CPT 28750. BMC Musculoskeletal Disorders The article is part of a PhD dissertation at the University of the Witwatersrand, Johannesburg, South Africa. Lesser metatarsophalangeal joint arthritis (primarily Freibergs infraction and post traumatic), may require surgical intervention once conservative management fails. HWnF}W The amputation code you used is not stated, but for a toe there are two CPT codes: 1) CPT 28820-Amputation, toe; metatarsophalangeal joint. A`WK7`1\_z_mZu~Dbj1tRI>J We continue to get rejected claims with the response from Novitas Medicare: code 151 payment adjusted because the payer deems the information submitted does not support this many/frequency of services. Connie Lee Bills, DPM, Mount Pleasant, MI, I think the discussion is over-generalizing. https://doi.org/10.1002/jor.22173. The initial simple silicone spacers and silicone ball [26] without stems were improved by the addition of prongs to increase stability. However, this can further weaken an already inflamed plantar plate and cause it to rupture completely. PubMed If you have NO first metatarsal-phalangeal joint bony overgrowth, bone prominence, bone budge, and/or bony lipping present (so obviously you can't correct it), and you have NO valgus rotation of the great toe present (so obviously you can't correct it), and all you do is perform a resection of the joint followed by insertion an implant, it would not meet CPT 28293 definition, and you should bill the unlisted foot procedure code, CPT 28899. I performed the resection and subsequently performed a delayed closure several days later. The procedures below may be performed as part of a hammertoe repair and should not be coded in addition to CPT 28285 when performed on the same toe: CPT Assistant also clarifies a key procedure that may be coded separately. Shih AT, Quint RE, Armstrong DG, Nixon BP. If you are a member and have already registered for member area and forum access, you can log in by clicking here. 1992;3(1):16-24. Each test station with its installed implants, was submerged in the de-ionized water (Fig. 14 - The four implants each with the respective compressive forces as well as the sizes after completing 5,000,000cycles at physiological forces). If it is approved, then the carrierwill need to price the unlisted procedure. The joint can be repaired by resurfacing the bones or replaced with a prosthesis. How would I code this? AS: Participated in the reviewing process and the cadaver trials. We certainly can submit electronically. Only the second metatarsophalangeal joint was tested. J Foot Surg. Classic example is the declining use of the proven benefit of diabetic shoes.
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