podiatry

Hi,

Wondering if I could get opinion on coding this?

Would this be CPT 28299? or CPT 28306 for the closing base osteotomy and 28298 for the Akin osteotomy with the soft tissue release included?

Closing base wedge osteotomy of the left first metatarsal with two screw fixation with Akin osteotomy of the left hallux.

Attention was first directed to the dorsal aspect of the left first metatarsophalangeal joint where a 6 cm linear longitudinal incision was made medial and parallel to the tendon of the extensor hallucis longus and involved the contour of the deformity. This incision was deepened through the skin and subcutaneous tissues using sharp and blunt dissection. Care was taken to identify and retract all vital, neuro and vascular structures. All bleeders were ligated and cauterized as necessary. Dissection was continued down to the level of the first metatarsophalangeal joint capsule, which was sharply incised with a #15 blade. All periosteal and capsular structures were reflected medially and laterally thus exposing the head of the first metatarsal at the operative site.
Next, a sagittal saw was utilized to resect the medial eminence from the medial aspect of the distal first metatarsal head. This was passed from the operative field. Next, attention was directed into the first interspace where a lateral release was performed with incision and release of the abductor hallucis muscle belly fibular sesamoid ligament and the extensor digitorum brevis tendon.

Once the lateral release was performed, attention was directed proximally to the area of the closing base wedge osteotomy. An apical axis guide was placed in the proximal lateral aspect of the first metatarsal shaft at the metaphyseal diaphyseal junction approximately 1 cm from the metatarsocuneiform joint that was made sure to be perpendicular to the weight-bearing surface.This axis guide was then utilized to create the laterally based wedge cuts that were approximate 45 degrees from this axis guide with the base proximally 2 mm in width. Once the wedge of bone was complete with a sagittal saw and removed and passed from the operative field. The osteotomy was closed and the first metatarsal was noted to be in a more correct position. Temporary fixation was placed utilizing K wires fromthe Stryker size 3-0 headed cannulated screw set and these were sequentially drilled and placed the first of which was perpendicular to the osteotomy site, the second of which was perpendicular to the shaft of the first metatarsal.
Fluoroscopy was utilized to inspect anatomic reduction, which was noted to be excellent. After completion of the osteotomy and fixation, attention was directed distally to the proximal phalanx of the left hallux where an Akin osteotomy was performed utilizing a K wire again as an apical axis guide perpendicular to the weight-bearing surface and utilizing a medially based wedge. This was performed with sagittal saw. The wedge was removed and the osteotomy was fixated utilizing a size 10 x 10 x 10 Stryker easy clip. Once again fluoroscopy was utilized to inspect anatomic reduction which was noted to be excellent. The metatarsophalangeal joint was inspected to be sure that there was no fixation entering the joint and none were found.
After completion of the Akin osteotomy, the surgical site was irrigated with copious amounts of normal sterile saline. The periosteal and capsular structures were re-approximated and coapted utilizing combination of 3-0 Ethibond and 3-0 Vicryl and the skin was re-approximated and coapted utilizing 4-0 Prolene. 
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