2025 CPT code 28289

Correction of hallux rigidus (stiff big toe) with cheilectomy (removal of bone spurs), debridement (cleaning), and capsular release (loosening of the joint capsule).

This code includes the application and removal of the first cast, splint, or traction device. Subsequent replacements may be reported separately. For obtaining autogenous bone grafts through separate incisions, use additional codes.There is no coding correlation between the type of fracture/dislocation and the type of treatment.

Modifiers may be applicable in certain situations, such as increased procedural services (modifier 22), bilateral procedures (modifier 50), or repeat procedures by the same physician (modifier 76).

Medical necessity for this procedure is established by the presence of symptomatic hallux rigidus that significantly impairs function and has not responded to conservative measures. Documentation should support the severity of symptoms and the impact on the patient's activities of daily living.

The surgeon makes an incision over the big toe joint, dissects through the soft tissue, and exposes the joint capsule.The capsule is opened, the joint is examined, and any loose bodies or abnormalities are addressed. Excess synovial tissue is removed, and bone spurs on the metatarsal head and proximal phalanx are excised using a saw. The eroded joint surface of the metatarsal head is also removed. Finally, bleeding is controlled, and the wound is closed in layers.

In simple words: Surgical correction of a stiff big toe involves removing bone spurs, cleaning the joint, and loosening the joint capsule to improve movement and reduce pain.

Hallux rigidus correction with cheilectomy, debridement and capsular release of the first metatarsophalangeal joint. This procedure addresses hallux rigidus, a condition characterized by pain and stiffness in the big toe joint due to arthritis. It involves removing bone spurs (cheilectomy), cleaning the joint (debridement), and releasing the tight joint capsule (capsular release) to improve movement and reduce pain.

Example 1: A 50-year-old patient experiences pain and limited motion in their big toe due to hallux rigidus.Conservative treatments like pain medication and physical therapy have failed to provide relief.The patient undergoes a cheilectomy, debridement, and capsular release to address the arthritis and improve joint function., A marathon runner develops hallux rigidus, impacting their training and performance.They choose surgical correction, involving cheilectomy, debridement, and capsular release, to restore range of motion and alleviate pain., An elderly patient with severe hallux rigidus has difficulty walking and performing daily activities.Surgical intervention with cheilectomy, debridement, and capsular release is recommended to improve their quality of life.

Documentation should include the diagnosis of hallux rigidus, failed conservative treatment attempts, operative report detailing the procedure performed (cheilectomy, debridement, capsular release), and post-operative care plan.

  • Specialties:Podiatry, Orthopedic Surgery
  • Place of Service:Ambulatory Surgical Center, Hospital Outpatient, Office
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