Medicare Compliance & Reimbursement

Cinderella surgery is categorized as any type of foot surgery that improves the appearance of the foot. This type of surgery can appeal to people who want to reshape their feet for a variety of reasons.

It involves shaving down bunions and sometimes changing the length of the toes, which can make it easier to wear certain shoes, but it is not always purely cosmetic. Cinderella surgeries may also help eliminate existing chronic pain that can come from wearing high heels.

Read on to learn more about coding these surgeries in your practice.

Nail Down Hammertoe Procedures

Hammertoes, also known as mallet toes, are a common foot problem where the joints in the toes become misaligned, causing them to point upward instead of lying flat. This condition can make affected toes appear bent all the time. Specifically, a hammertoe occurs when the tip of the toe points downward while the middle joint curls upward. It is most common in the second joint of the lesser toes.

There are two different types of hammertoes:

• Flexible hammertoe: If the patient’s toe can still be moved at the joint, then it’s a flexible hammertoe. This type is considered an earlier, milder form of the condition.
• Rigid hammertoe: If the tendons in the patient’s toe have become rigid, then they will press the joint out of alignment and the toe can’t move. Rigid hammertoe is considered more developed than flexible hammertoe.

To fix a flexible hammertoe, the surgeon can perform a flexor tendon release, or tenotomy, which you’ll report with 28232 (Tenotomy, open, tendon flexor; toe, single tendon (separate procedure)).

“Often, this less invasive procedure will give full relief to the patient with minimal recovery time. But be aware that 28232 cannot be billed with 28285 [Correction, hammertoe (eg, interphalangeal fusion, partial or total phalangectomy)] for the same toe. If two separate toes are repaired on the same day, you may bill with the 59 modifier [Distinct procedural service],” advises Jeri L. Jordan, CPC, billing manager at Hampton Roads Foot and Ankle in Williamsburg, Virginia.

To fix hammertoe permanently, the patient will need surgery; and for rigid hammertoe, surgery is the only possible treatment option. During the procedure, the surgeon will roughen up the cartilage on the base of the middle phalanx to promote arthrofibrosis, and the toe is then straightened and fixed with a K-wire.

In this situation, you can report this procedure with 28285.

Understand Bunion Removal Procedures

A bunion is defined as inflamed swelling of the small fluid-filled sac on the first joint of the great toe accompanied by enlargement and protrusion of the joint.

“In truth, a bunion is a foot deformity,” explains Jordan. “Usually, the big toe bone curves instead of being straight, which can cause the bone to jut out of the side of the foot. The technical term for a bunion is hallux valgus, but there are different conditions such as hallux rigidus and hallux limitus, to name a few. When billing for a bunion, make sure to use the most specific diagnosis code available for your procedure.”

CPT^® codes to consider for bunion procedures include:

• 28292 (Correction, hallux valgus with bunionectomy, with sesamoidectomy when performed; with resection of proximal phalanx base, when performed, any method)
• 28295 (… with proximal metatarsal osteotomy, any method)
• 28296 (… with distal metatarsal osteotomy, any method)
• 28297 (… with first metatarsal and medial cuneiform joint arthrodesis, any method)

The work for 28292 includes the physician removing prominent or hypertrophied bone from the medial aspect of the patient’s first metatarsal head. This work may also include the physician resecting excess bone at the dorsomedial, dorsal, and/ or dorsolateral aspect of the metatarsal head and/or base of the proximal phalanx.

Additionally, for a 28292 service, your physician may perform tendon and other soft tissue balancing and a transverse resection of the proximal phalanx base. Your physician may also remove either one or both sesamoids.

However, the work for code 28292 does not include any osteotomy or fusion procedures, according to CPT^® Assistant, Vol. 20, No. 12.

Osteotomy defined: An osteotomy is a procedure to correct a deformity where the surgeon cuts the big toe joint in various places along the bone and realigns it to a normal position, according to Jordan. Additionally, there are times where the surgeon may remove a small wedge of bone to allow the toe to straighten.

The work for 28295 includes the removal of prominent or hypertrophied bone from the medial aspect of the first metatarsal head. However, unlike 28292, code 28295 does include a proximal first metatarsal osteotomy.

Code 28295 may also include the resection of excess bone at the dorsomedial, dorsal, and/or dorsolateral aspect of the metatarsal head; and/or base of the proximal phalanx.

Code 28296 is the most commonly coded bunionectomy procedure. This code includes the removal of prominent or hypertrophied bone from the medial aspect of the first metatarsal head. This code includes a distal first metatarsal osteotomy. Additionally, your physician may perform a resection of excess bone at the dorsomedial, dorsal, and/or dorsolateral aspect of the metatarsal head; and/or base of the proximal phalanx.

Code 28297 includes several specific services such as the removal of prominent or hypertrophied bone from the medial aspect of the first metatarsal head, along with first metatarsal and medial cuneiform joint arthrodesis. This code may also include when your physician resects excess bone at the dorsomedial, dorsal, and/or dorsolateral aspect of the metatarsal head, and/or base of the proximal phalanx with or without related soft-tissue correction, resection, or release.

Get Up to Speed on Toe Shortening Procedures

The primary purpose of toe shortening is to address functional or aesthetic concerns related to the toes. Some common reasons for toe shortening include correcting a condition called brachymetatarsia, where one or more toes are abnormally short compared to the others, resolving discomfort or pain caused by excessively long toes that may rub against footwear or cause difficulty in finding properly fitting shoes, and improving the overall appearance of the foot by creating a more balanced and proportionate toe length.

CPT^® codes you would look to for toe lengthening or shortening include:

• 28308 (Osteotomy, with or without lengthening, shortening or angular correction, metatarsal; other than first metatarsal, each)
• 28309 (… multiple (eg, Swanson type cavus foot procedure))
• 28310 (Osteotomy, shortening, angular or rotational correction; proximal phalanx, first toe (separate procedure))
• 28312 (… other phalanges, any toe)
• 28341 (Reconstruction, toe, macrodactyly; requiring bone resection). Note: This will shorten a longer second toe

Know this: For a general toe deformity repair, you would choose code 28313 (Reconstruction, angular deformity of toe, soft tissue procedures only (eg, overlapping second toe, fifth toe, curly toes).

Beware of Denials

To avoid claim denials related to medical necessity, the practitioner’s notes must illustrate that the surgery was essential due to the patient experiencing pain or discomfort. Obviously, anything purely cosmetic would become the responsibility of the patient.

Lindsey Bush, BA, MA, CPC, Development Editor, AAPC