2nd metatarsal joint replacement cpt 2nd metatarsal joint replacement cpt

$"j/Fr For my visual learners, check out this image of a hammertoe: Hammertoe. 2014;13(4):199205. Comparison of the effects of forefoot joint-preserving arthroplasty and Forty adult skeleton feet were used as per the statisticians advice. I was looking at CPT 27641, but the description says that is for osteomyelitis. Finally, it is also appropriate to code CPT 28285 for repair of a claw toe deformity with extensor tenotomy and flexor tendon transfer. California Privacy Statement, Post-operative stability was objectively assessed for dorsal displacement and dorsiflexion using a 5kgf (49N) and was found to be excellent. Autograft interpositional a. The amputation code you used is not stated, but for a toe there are two CPT codes: 1) CPT 28820-Amputation, toe; metatarsophalangeal joint. Salvage surgery for failed toe joint replacement - Mayo Clinic The four implants each with the respective compressive forces as well as the sizes after completing 5,000,000cycles at physiological forces. Following these tests, it was implanted in 15 fresh frozen cadavers at various stages of its development, during which the surgical technique was perfected. Some will present in their senior years having a long-standing untreated bunion and overlapping second toe that simply wont fit into a shoe. This condition may become debilitating in the younger individual. Lesser metatarsophalangeal joint implants. Arthroscopic interpositional arthroplasty of the second metatarsophalangeal joint. This study is the basis for clinical trials (the implant has been cleared for clinical trials by Human Ethics of the University). CPT 28122 Musculoskeletal partial excision (craterization, saucerization, or diaphysectomy) of bone (e.g., for osteomyelitis or tarsal bossing), tarsal or metatarsal bone, except talus or calcaneus. The first metatarsophalangeal joint arthrodesis could not be performed unless the implant was first removed from the first metatarsophalangeal joint. However, this is what Anthem Blue Cross wants. >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'cB=@jXVxvI.4@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 . Podiatry Management 400 Cranberry Ln, West Chester, PA 19380, Copyright 2023, Podiatry Management Online - All Rights Reserved. When we billed these codes, our EMR system and our clearing house rejected the codes. & Strydom, A. 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). Lesser Metatarsal Metallic Hemiarthroplasty. Male and younger female patients tend to be athletic (runners, weight lifters, baseball catcher, etc.) They know what to expect. gQEsSsAorL)'+ _'B>-Sy"NJLDY;sf&sN37Xej-MdiXK L_>%SY?xbR -ia(5E6"p;gm&F {{@MZd+(e(iFl\?jt.SoB5o#p, 29bN??oZ;tLVs12F1imsr#sD`4RJ7vSjO-Foxb#.,*Zv^dcJC `NNCGs1X67VcdYX Joint replacement arthroplasty has been used in the end stages of the disease . 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. Anthem denied both claims stating invalid modifiers. . inappropriate to use. If you are a member and have already registered for member area and forum access, you can log in by clicking here. https://doi.org/10.7547/0940590. Silicone [17,18,19,20,21,22,23,24,25,26], ceramic [30] and metal LMTPJ arthroplasty [27, 28] have been reported with mixed success. Purpose The purpose of this retrospective study is to clarify the difference in plantar pressure distribution during walking and related patient-based outcomes between forefoot joint-preserving arthroplasty and resection-replacement arthroplasty in patients with rheumatoid arthritis (RA). 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. Can audio only telephone calls be reimbursed? The only code needing a -59 or -XS is CPT 28750. The joints were stable both pre- and post-operatively. Freiberg's Infraction of the Second Metatarsal Head with - FAOJ There was a change January 1, 2021 to make the toe amputation codes ZERO day global. Fusion of either of these joints is included in CPT 28285. Arthroscopic interpositional arthroplasty for Freibergs disease. The answer to this question depends on the contracts and should be asked of a healthcare attorney. el-Tayeby HM. If a patient asks for bilateral injections or some other service that we know has been rejected in the past and we know will be on this particular date, what are we supposed to do? Tell the patient your insurance wont allow me or your insurance wont pay for that? The indication for surgery is when this joint has a fixed curved (Clawtoe or Hammer Toe) deformity and when the deformity is producing enough pain or functional limitations to warrant surgery.The deformity develops gradually and cannot be straightened because it is . Google Scholar. Classic example is the declining use of the proven benefit of diabetic shoes. The incision is deepened between the extensor digitorum longus and extensor digitorum brevis tendons down to capsule. The only good news about this situation is that the MUE Adjudication Indicator (MAI) is 3. The implant was manufactured free of charge by Southern Medical (SA). Highly-polished Cobalt Chrome articular surface. for implant arthroplasty of the 1st MPJ for. It was denied with a CO-16 error code. 1979;69(9):55661. The closure left an area open due to soft tissue deficit. 1984;23(1):3540. Implant arthroplasty of the lesser metatarsophalangeal joint a modified technique. I have received several requests from Ciox asking for patient charts. or recall a traumatic event that precipitated their condition, such as running up a flight of stairs and stubbing the toe and feeling a sudden pop sensation beneath the toe (. Manage cookies/Do not sell my data we use in the preference centre. endstream The ASC needs to add codes 28270-59-T1 and 28270-59-T2 [capsulotomy; metatarsophalangeal joint, with or without tenorrhaphy, each joint (separate procedure)]. The original post-operative global period of 90 days for the performance of the hallux arthroplasty stays in place despite the performance of the 2nd procedure, the amputation of the hallux. The implant is considered to be more of a resurfacing rather than a metatarsal head replacement so as not to interfere with the plantar condyles of the metatarsal head. Such injuries are rare but potentially serious. However, this can further weaken an already inflamed plantar plate and cause it to rupture completely. Does anybody know a different modifier to use when billing CPT 28297 (Lapidus bunionectomy) to delineate right and left foot? What a travesty to the patients, the doctors providing them, and the system. Miller ML, Lenet MD, Sherman M. Surgical treatment of Freibergs infraction with the use of total joint replacement arthroplasty. 5 Hallux disarticulation for application of electro-goniometer). Anyone you share the following link with will be able to read this content: Sorry, a shareable link is not currently available for this article. https://doi.org/10.1097/BTF.0000000000000065. Scartozzi G, Schram A, Janigian J. Freiberg's infraction of the second metatarsal head with formation of multiple . Shih AT, Quint RE, Armstrong DG, Nixon BP. The goals of operative treatment are correction of the deformity and rebalancing of the deforming muscle forces. Laparoscopic Excision of a Peritoneal Mass (49203 vs. 49329), CMS vs. CPT: No NCCI Edits for Imaging Guidance During Nerve Blocks, NCCI Edits for CPT 29823: A Return to Normalcy from CMS, Removal of the phalangeal base (CPT 28126), Capsulotomy of the interphalangeal joints (CPT 28272). Stability of the metatarsophalangeal joint of the lesser toes: a cadaveric study. Wright JG, Einhorn TA, Heckman JD. J Am Podiatry Assoc. . 2015;54(2):23741. They will even go so far as to try to negotiate a price per chart. https://doi.org/10.2106/00004623-200509000-00001. The Nicolle, the Calnam-Nicolle and the Niebauer-Cutter hinged prosthesis had been adapted for LMTPJ arthroplasty. This proof of concept study has shown this LMTPJ replacement to be simple in its surgical technique requiring minimal specialized instrumentation, achieving good range of motion and stability, albeit the inferior quality of cadaveric tissue, with good surgical reproducibility. 1988 Aug;9(1):10-8. doi: 10.1177/107110078800900104. I suggest the following: APMA members should submit their good notes with the EOMBs to APMA. unless the diagnosis specifically has. Edited by Robert Leland, MD Indication. I am not sure where you compared these two but on the. J Foot Surg. Freed JB. The implant may be used as a total or hemi arthroplasty. 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. Cyclical testing instrumentation four stations. The 2nd TMT joint is approximately 1-2 cm proximal to the 1st TMT joint. I did suggest APMA get to threatening the health plan with exposure and recommending legal action, class actions, etc. Total ceramic arthroplasty has been reported by Townshend and Greiss for painful, destructive disorders of the lesser MTPJs. The LMTPJ dorsiflexion both pre- and post-implant varied widely from 12 52 and 20 41 respectively with an average of 28.5 and 28.9 respectively. The interpositional arthroplasty procedure in treatment of degenerative arthritis of the second metatarsophalangeal joint. I have tried to look up codes and asked around but have not come up with a good option. Silicone implant arthroplasty for second metatarsophalangeal joint disorders with and without hallux valgus deformities. Website Design by S. Kloos Communications Inc. The aim of this study is to evaluate this novel replacement arthroplasty of the lesser metatarsophalangeal joint in a laboratory setting and cadaver implantation. Interpositional free tendon graft for lesser metatarsophalangeal joint arthropathy. 1 It typically involves progressive osteophyte formation and cartilage destruction resulting in joint pain, stiffness and restricted dorsiflexion of the first MPJ. Stability was divided into stable, lax and dislocatable. The materials used in this implant (titanium and UHMWPE) are accepted internationally and the titanium nitride is proven to enhance surface hardness. This force was shown on previous cadaveric studies to disrupt the soft tissue stabilizing factors of the LMTPJ and is thus seen as very conservative. It would be nice to see them punished financially for their purposeful denial of legitimate claims to bolster their profits. The sizes of the metallic components (metatarsal and phalangeal) were determined by the accurate measurement of the respective bones on skeleton specimens. 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. Here is where CPT Assistant provides more insight on what additional procedures may be included in repairing a hammertoe. For the purpose of testing this medical implant, a mechanical test apparatus was designed in conjunction with bioengineers and manufactured to simulate the articulation of the LMTPJ in the human foot. The cadavers were supplied by Smith & Nephew (SA). Ciox is relentless at calling our office and repeatedly sending faxes requesting charts. We performed a destruction of a painful wart in the clinic. What is included in the CPT code 28285? 1989;1:113. 2023 CPT Changes for Surgery Now Available - click on Shop to learn more! volume22, Articlenumber:424 (2021) Each author certifies that he has no commercial associations that might pose a conflict of interest in connection with the submitted article. Foot Ankle Int. 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. The edges of the metatarsal head is contoured by debridement of all osteophytes in order to restore a spherical head. Google Scholar. You have to abide by the insurance company rules -as you signed a contract with them-or you could get in trouble. Connie Lee Bills, DPM, Mount Pleasant, MI, I think the discussion is over-generalizing. Other potential treatment options include implant arthroplasty, metatarsal head resection, debridement only, and soft tissue interposition. J Foot Ankle Surg. PubMed David J Freedman, DPM, CPC, Silver Spring, MD. A hammertoe is a deformity where the interphalangeal joint pops up instead of lying flat, giving the toe the shape/appearance of a hammer. Are we allowed to ask the patient to pay for the non-covered service? If this procedure is done in conjunction with a Hammertoe (28285) procedure, it would Payer rules related to modifiers further complicate the claims submission process and increase the challenges faced by the appeals team. Answers to your questions on foot and ankle coding Reporting services for foot and ankle proceduresespecially surgery on the toesis challenging. Lavery L, Harkless LJTJ. It may be from normal motion with no crepitation to rigidity of the toe and MTPJ. The LMTPJ plantar flexion also varied widely from 22 52and 8 35 respectively with an average of 33.8 and 20.8 respectively (Table3). Any suggestions? 2018;39(11):1290300. 1989;28(3):1959. This new lesser metatarsophalangeal joint replacement is based on a three-component implant. We are being taken advantage of. Toe Amputation CPT (2022) Description, Guidelines, Reimbursement Depending on the stage of deformity, signs and symptoms will vary at the initial time of presentation. Once the PHE is deemed over, one will need to check back to see what changes from pre- and post-PHE have been retained and which ones are discarded. My HCA surgery center and their coding company has consulted with 3M and Precyse (coding and billing), as well as the AMA regarding the use of the CPT 28293 (correction, hallux valgus [bunion], with or without sesamoidectomy; resection of joint with implant) code. Saragas, N.P., Ferrao, P.N.F. Ethics approval for this study was obtained from the Wits Human Research Ethics Committee. Notice, though, that in the parentheses of the code description for CPT 28285, we have an e.g., listed before those procedures. Knee Surg Sports Traumatol Arthrosc. Anybody have any advice? 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. Something changed and are we missing something with the modifiers? Podiatry Management Online <> There was osteomyelitis of the proximal phalanx and metatarsal head. The authors hypothesize that the design of this implant will effectively simulate the lesser metatarsophalangeal joint in both laboratory setting and cadaver trials so as to follow with clinical trials. The revision procedure involves removal of the implant and reconstruction of the great toe to restore function and relieve pain. Stability and range of motion is checked. There are no more messages in this thread. A total of four dorsiflexion and plantar flexion measurements were included in the study. I just received reimbursement for a hallux amputation for a patient I managed while they were admitted to the hospital. 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. Everything You Need To Know About Arthroplasty Surgery - Foot Vitals PIP (Proximal Interphalangeal) Joint Fusion. Has anybody else had that problem and if so, what was done to correct it to get payment? A cannulated reamer is then used to prepare the metatarsal head (Fig. The higher co-payments above the approved amount are how the insurance companies pay nothing and have shifted costs to the patients. This code is used is the joint capsule released lies between the tarsal and the toe. In addition, the test apparatus was covered for the duration of testing to prevent any foreign debris from entering the test environment. Cyclical loading of 5,000,000cycles within physiological forces showed minimal wear of both the metatarsal implant and polyethylene meniscus. The compressive forces were applied during cyclic articulation by means of cylindrical helical silicone compression springs. https://doi.org/10.3113/FAI.2008.0488. Per the OR report: ". The issue here is not whether or not you can report 28291 because in most instances you can, but whether or not the device being implanted is an approved device based on the patients insurance plan. The average plantar flexion was 33.8 and 20.8 pre- and post- implant respectively. Shih et al. hbbd```b``~ "WH&}=&6VifH d 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. PDF Surgery of the Foot - UHCprovider.com This is an in vitro and cadaver study of a new design replacement arthroplasty developed by the senior author. J Foot Surg. Previously we reported 28293 when a hemi- or total joint arthroplasty was performed at the first metatarsophalangeal joint but that code was deleted in 2017 and replaced with 28291 Hallux rigidus correction with cheilectomy, debridement and capsular release of the first metatarsophalangeal joint; with implant. RE: Aetna Medicare Advantage (Lori Stack). 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. 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. One case required a custom implant. If I have a $250 co-payment for every visit to the ER, I pay $250, even if they tell me to go home and call a podiatrist for the ingrown toenail. 9 - Complete lesser metatarsophalangeal replacement in situ). The implants were subjected to 5 million cycles, after which wear damage at the contact surface of each implant was captured by means of photographic imaging and thickness measurements of the meniscus. Article All of the above listed CPT codes have a post-operative global period of 90 days. 29827. PNFF: Participated in the cadaver trials, interpreted the results of the study and participated in the reviewing process. Even though the CPT code changed, the guidelines that apply to this code have not. hb```b``6f`e`` @16< HWnF}W The Laboratory apparatus and testing equipment were self funded by NPS. Article . ANATOMY OF THE PLANTAR PLATE. 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). Appeals are a waste of time. Flood them with this and demand they use your dues money to lawyer up, pay billing experts, and fight them. A screw implanted into the proximal phalanx was used for this purpose (Fig. Nicolle finger joint prosthesis: a preliminary study of total joint replacement for lesser metatarsophalangeal joints. Does one have to record the video or audio in order for it to be reimbursed or could one just take notes? The paperwork and hoops to jump through have become so egregious, many doctors have simply stopped prescribing/dispensing them. The mobile bearing can rotate 360. Use of the Classic Hemi-Cap toe implant is a resurfacing procedure. Google Scholar. Codes 26535 and 26536 are not used to classify arthroplasty of the finger's interphalangeal joint. Enriquez Castro JA, Guevara Hernandez G, Estevez DG. This was a small cohort with short follow-up. the "Hallux valgus or bunion". How would I code this? How can a surgical procedure for a patient with a bone infection pay less than an order from Panera? 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. 68% associated with fracture of 2nd or 4th metatarsal. In effect, AMA has indicated that CPT 28293 is inappropriate to use unless the diagnosis specifically has the "Hallux valgus or bunion" phrase, and that unlisted procedure code, CPT 28899, should be used for implant arthroplasty of the 1st MPJ for other diagnoses such as hallux limitus, hallux rigidus, or hallux varus. Three mm of the base of the proximal phalanx is excised using an oscillating saw and the proximal phalanx is hyper plantar flexed. Instead of a transverse ligament between the 1st and 2nd metatarsal, there are plantar, interosseous, and dorsal oblique ligaments that runs from the medial cuneiform and the base of the 2nd metatarsal. https://doi.org/10.1016/j.fcl.2011.08.008. Carriers are trying to bundle all that they can and that really hits home on the E/M usage and modifiers. A novel implant was designed and developed by the senior author (NPS) (Fig. The example given is for osteomyelitis, but it is not saying it is the only example; it is just one example. The phalangeal component is then screwed into the phalanx. fWji`/^ !DMA$jQ$`: 2Il{ ,8X=(I?CI #zI Metatarsophalangeal joint and plantar plate repair - AHA Coding Clinic 2008;22(4):25962. which marvel character matches your personality. Contact your sales rep. Metatarsal Osteotomy - an overview | ScienceDirect Topics Teich LJ, Frankel JP, Lipsman S. Silicone hinge replacement arthroplasty. endstream endobj 600 0 obj <> endobj 601 0 obj <> endobj 602 0 obj <>stream 1992;31(6):5904. The implant was inserted in a further two cadavers by an independent foot and ankle surgeon to check reproducibility. The x-rays adhered to the international standard weight bearing protocol of foot x-rays. Removal of Implant and Conversion to Fusion | TLD Systems The metatarsal component is then inserted into the metatarsal head and gently impacted in place (Fig. Ed Prikaszczikow, DPM, Council Bluffs, IA, Query: Lapidus Bunionectomies and Anthem Blue Cross. :VD#;CQyil-Za`8Hx]+x EN.6.O+@F qmq{`S?dfbj6!>*6>ULpXyK~emmH|NN|`>#k*|-04G_S{LrsU jCNW0$# CI<0j$ S~oFjRNi86|]=|` t$ The site navigation utilizes arrow, enter, escape, and space bar key commands. Townshend DN, Greiss ME. 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. Article May 2020. Tintocallis CA. Significant wear was evident on all four inserts after testing at excessive forces (Fig. 1) CPT 28820-Amputation, toe; metatarsophalangeal joint, 2) CPT 28825-Amputation, toe; interphalangeal joint. 1988;9(1):108. zkan Y, Ozturk A, zdemir R, Aykut S, Yalin N. Interpositional arthroplasty with extensor digitorum brevis tendon in Freiberg's disease: a new surgical technique. The definition shows it is a partial excision of bone of the fibula. Sgarlato T. A new implant for the metatarsophalangeal joint. That said, make sure you are 100% sure of the rules regarding that service. For these reasons the author developed this LMTPJ replacement. [2] Patients usually present with a painful and often swollen joint. Once the soft tissue is well balanced, the correct size polyethylene is inserted into place (Fig. Policy Aetna considers the following procedures medically necessary for persons with disabling arthritis of the first metatarsal phalangeal joint (hallux rigidus): For clinical trials, as with other replacements, the ideal candidate must be sought, followed by the stringent principles of replacements and informed consent. The articulation was generated using a 12-VDC torsion motor capable of articulating each implant device to a pre-set angle at a frequency of 3Hz. 2011;16(4):64758. 2013;34(10):143642. https://doi.org/10.1002/jor.22173. The metatarsal component fixation mechanism is unique. These implants were subjected to 5 million cycles each at physiological compressive forces of 3N, 4N, 6N and 8N respectively [ 31]. J0702 Injection, betamethasone acetate 3 mg and betamethasone sodium phosphate 3 mg, J3301 Injection, triamcinolone acetonide, per 10 mg, J3302 Injection, triamcinolone diacetate, per 5 mg. 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. Unfortunately, an infection developed following the procedure, necessitating an amputation of the hallux to be performed. Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. I coded it CPT 20550 -LT and CPT 20550 -RT. The stability was excellent in both dorsal displacement and dorsiflexion. 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. Surgical arthroscopy of the shoulder, rotator cuff repair. Lesser metatarsal metallic hemiarthroplasty. Its not your fault this the service is covered or not. The private insurance is stating that all the CPT 11042 billings are considered part of the global. The hallux had to be disarticulated at the metatarsophalangeal joint (MTPJ) in order to accurately test the range of motion of the implanted device with a custom-made measuring tool (Fig. Are these ever for pre/post payment claim reviews or only for data mining? This procedure may be considered when conservative treatments no longer provide adequate relief from joint pain and/or disability. Second metatarsophalangeal joint fusion: A new - ScienceDirect That has apparently gone by the wayside. Many of the arthroplasty implants are considered experimental/investigational and not covered by the patients policy. It is in my opinion, a tremendous waste of time and resources versus having clear cut policies which are transparent and available to all providers. Foot Ankle Clin. endstream endobj 595 0 obj <>stream I think a better solution would be that the next person that gets denied for the same problem start a class action lawsuit. the metatarsal head and removal of part of the proximal phalanx, leaving a flexible joint [e.g., Keller's arthroplasty]), arthrodesis (i.e., excision of the metatarsal head along with part of the proximal phalanx, and fusion of the joint), and implant arthroplasty (i.e., partial or total joint replacement with an artificial implant).