AHA Coding Clinic® for ICD-10-CM and ICD-10-PCS - 2021 Issue 2; Ask the Editor

Excision of Tibial Sesamoid

A patient presents for excision of the right tibial sesamoid bone secondary to osteomyelitis. During surgery, an incision was made medial to the first metatarsal. After dissection, the ligaments and soft tissue surrounding the tibial sesamoid were cut in order to excise the bone. The soft and discolored sesamoid was removed and sent to pathology. Is the sesamoid considered a separate bone and coded to the root operation Resection? Conversely, is the tibial sesamoid an extension of the metatarsal and coded to the root operation Excision? What is the appropriate body part value? How is a tibial sesamoidectomy coded? ...

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