Orthopedic Coding Alert

An amputation surgery means that bone is being cut through and removed from the body of the patient. A surgical amputation could be the result of an accident or an earlier, deliberate surgical procedure that became infected or is severe enough to warrant removal of a limb or digit. When coding for amputation of fingers and toes in particular, coders should remember that tissue loss only does not constitute an amputation.

The Injury

Billie Jo McCrary, CPC, CCS-P, CMPC, practice manager of Wellington Orthopaedic and Sports Medicine in Cincinnati, a six-office practice with 18 physicians, shares an operative report of a two-stage toe amputation that presents some coding challenges. The surgery was performed on a 42-year-old male who had nearly amputated two of his toes in a lawn mower accident.

Indications for Operation

The patient) sustained near amputation of the right second toe through the base of the distal phalanx and a near amputation of the right great toe through the base of the distal phalanx. X-rays revealed comminuted fractures of the affected toes and clinical exam revealed significant soft tissue defects with a thin bridge of skin attaching the residual portion of the second toe and an oblique laceration through the germinal matrix of the great toe. X-rays also revealed that the distal half of the great toe distal phalanx was missing. There was a ragged dorsal flap of the great toe dorsally, which was attached by a bridge of skin medially.

In the Operating Room

Second toe: A bone resection through the interphalangeal joint of the second toe was carried out sharply with a knife. All skin edges were then resected along a 2-mm margin to remove all contaminated tissue. The subcutaneous layer was debrided as well sharply with a knife and a rongeur under loupe magnification.

Great toe: The distal portion of the distal phalanx was debrided with a rongeur and all bone edges were smoothed. The interphalangeal joint was stable and therefore the remainder of this bone was saved after it was debrided back to a clean margin. The subcutaneous layer was further sharply debrided under loupe magnification, removing all contaminated tissues. All skin edges were resected back to a 1- to 2-mm margin. The subcutaneous layer was then debrided. The skin edges were trimmed to provide for later flap closure.

The wounds on both toes were left open, with a plan to bring the patient back to the operating room (OR) within 36 to 48 hours for repeat irrigation, additional debridement and delayed primary closure. Upon return to the OR, additional debulking of subcutaneous tissue of the great toe was done, as was additional debridement of the subcutaneous tissue of the second toe. Both wounds were irrigated, a drain was placed, and the flaps on both toes were closed without difficulty.

Coding the Surgery

Coding for the surgery is complicated on many levels. For starters, the patient was first seen by the orthopedic surgeon in the emergency department (ED) and taken to surgery shortly thereafter. Second, the return to the operating room days later was a staged procedure with its own coding implications. Last, multiple codes and modifiers are needed to indicate that surgery was performed on more than one location in the same surgical setting.

For the initial call to the ED, McCrary can bill for initial hospital care (99221-57, initial hospital care, per day, for the evaluation and management of a patient ...
-decision for surgery) because the patient was admitted and the three key components were met, including detailed or comprehensive history and examination as well as medical decision-making (decision for surgical amputation) of straightforward or low complexity. Use of 99221 instead of a higher-level code assumes that apart from the injury, the patient was in good health with no complicating conditions as none were noted in the documentation.

For coding the second toe, the closest code to describe the service performed is 28825 (amputation, toe; interphalangeal joint). The amputation code is appropriate here because according to the op report, a bone resection through the interphalangeal joint was carried out. A digit modifier would be used to indicate which toe was treated. Although CPT has its own modifiers for multiple procedures or distinct procedural services, which could be used to indicate multiple digits, the HCFA modifiers listed in CPT 2000 are the more commonly accepted in lieu of the CPT modifiers, as they are more specific. Therefore the procedure on the second toe would be coded as 28825-T6 (right foot, second digit).

For the great toe, coding is not so straightforward. A closer look at the op report reveals that bone was not cut in the great toe, it was only debrided, thus the procedure is not an amputation. It also would not qualify for an open repair of the fracture, as the broken bone fragments are not salvaged because they are missing. Rather, 11012 (debridement including removal of foreign material associated with open fracture[s] and/or dislocations; skin, subcutaneous tissue, muscle fascia, muscle and bone) covers all of the treatment on that toe during the initial operative setting.

Coding the Follow-up Surgery

For the follow-up surgery, grafting code 14040 (adjacent tissue transfer or rearrangement, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet; defect 10 sq. cm. or less) is used because an advancement flap was prepared at the first operative session and finished during the second session.

Debridement is included in the graft code unless it is extensive and documented that way, as is not the case here. This code applies for both toes and should be listed twice on the claim form with the appropriate modifiers for the toes (-T5, right foot, great toe; -T6, right foot, second digit).

For the staged procedure, says James Guerra, MD, of Collier Sports Medicine and Orthopedic Center, a two-physician practice in Naples, Fla., code 14040 would be billed with a -58 modifier (staged or related procedure or service by the same physician during the postoperative period). Use of the -58 will result in a reduced payment. Guerra explains that fees for staged procedures like the one described here, although a complete surgery in and of itself, are reduced by carriers because they fall within an existing global period (for the initial trip to the OR). The rationale, says Guerra, is that the global periods for the 28825 and the 11012 assume 90 days worth of care will be given. The procedures are being done to address one problem and do not constitute two separate sets of care. Consequently, the final claim would read as follows for the first surgery: 28825-T6, 11012-T5.

According to Susan Callaway-Stradley, CPC,
CCS-P, an independent coding consultant and educator in North Augusta, S.C, some carriers might want the -51 modifier for multiple procedures in addition to, or instead of, the digit modifiers, and some may require -59 (distinct procedural service) instead of digit modifiers. It is always a good idea to contact carriers in advance to determine which prefer the less common modifier configurations, says Callaway-Stradley.

The second, staged surgery would read 14040-58-T5, 14040-58-T6. Again, says Stradley, some carriers may also require some mix of the -51 or -59 modifiers in addition to the above-listed modifiers, but the digit modifiers should suffice in addition to the staged modifier. Expect reductions for the second procedure each day no matter what modifier combination is used.