Orthopedic Coding Alert

Make sure you're using the correct modifier and that you check with your payor.

Think twice before you report flexor tenotomy with hammertoe correction. The National Correct Coding Initiative (NCCI) doesn't bundle the two services together, but you'll need to exercise caution before you can claim the two together. See our advice below for how and when can you report 28285 (Correction, hammertoe [e.g., interphalangeal fusion, partial or total phalangectomy]) for hammertoe correction and 28232 (Tenotomy, open, tendon flexor; toe, single tendon [separate procedure]) for the flexor tenotomy on the same toe when your surgeon performs these procedures.

"Medicare does not always incorporate the CPT® "separate procedure" codes into the NCCI edits, but rather assumes that the coder will recognize coding scenarios in which a procedure or procedures are an integral part of the progression to the end procedure and, therefore, may not be billed separately," says Josie Dunn, CPC, Department of Orthopaedics, University of Maryland Faculty Practices, Maryland.

Know What 28285 Includes

The code 28285 is inclusive of extensor tenotomy. "The open flexor tenotomy (28232) is designated as a separate procedure by CPT® ; however, only an extensor tenotomy is considered to be bundled into 28285 according to AAOS Global Service Data," says Ruby O'Brochta-Woodward, BSN, CPC, CCS-P, COSC, ACS-OR, compliance and research specialist, Twin Cities Orthopedics, P.A. 

Payor challenges: You may face payor push-back for flexor tenotomy claims as some payors may just refuse to accept the flexor tenotomy as separate. "I would not report 28285 and 28232 together on the same toe, as the AOFAS states the work performed doing the tenotomy is included in 28285, either extensor or flexor," says Leslie A. Follebout, CPC, COSC, senior orthopaedic coder and auditor, The Coding Network, Beverly Hills, California. There is, however, a possibility that you report the two as separate procedures. "Since the flexor tendons are located on the plantar side of the foot if performed open (28232) or percutaneously (28010 [Tenotomy, percutaneous, toe; single tendon]), they may be performed through a separate incision or at a different level (DIP vs PIP) allowing for separate reporting," says Woodward. "Medicare recommends -- Whenever you are coding for procedures and services, it is important to consider  procedures services that are routinely viewed as an integral part of another more extensive procedure," says Dunn.

"I have an AMA reference that deems flexor tenotomy inclusive to code 28285. I would not report code 28232 in addition to 28285 when performed on the same toe," says Stout.

Turn To Modifier 59

You may earn your payment if you append modifier 59 to 28232 when reporting it with 28285. "For many payors, a 59 modifier would be required due to the separate procedure designation. For many payors, it is still difficult to get this code combination paid," says Woodward. "If surgical correction is needed as described in code 28285, and your physician needs to do 28232 (separate procedure)  tenotomy  toe, single tendon, you should add modifier 59 to this procedure unless your physician stated  it was an integral part of the procedure," says Dunn.

Report Two Codes For Two Toes

Payors differ in how they view reporting of hammertoe corrections in two toes. "Reporting 28285 on multiple toes sometimes will be trial and error, as different payors will require different modifier assignment," says Follebout.  "I would start with 28285-T1 and 28285-59-T2 for a hammertoe repair on the left 2nd and 3rd toes for example.  Some payors may not require the -59 if the digit modifiers are used." "If your physician corrects more than one toe, some payers may require you to use level II modifiers T1-TA," says Dunn. "In this situation, I report 28285-T1 and 28285-T2-51 (Multiple procedures...)," says Stout.

Use The T Modifier

Adopt the T guidelines for Medicare. "For Medicare and those who follow Medicare as well as those who follow CPT® guidelines, the T modifiers alone should be sufficient," says Woodward. You will select a separate code for each digit in your claim, if your surgeon performs hammertoe corrections on several toes. You will append modifiers such as 28285-T8 -- Right foot, fourth digit and 28285-T6 -- Right foot, second digit. "Use the T modifiers to show the distinctly separate digits.  Under the CMS definition for the 59 modifier, only the T modifiers should be required, not a combination of the T modifiers AND the 59 modifier unless 28285 is also considered bundled with another procedure performed on the same digit, says Woodward.

Tip: Check if your surgeon is doing a tenotomy on one toe and the hammertoe correction on another. You then use T modifiers to separately identify the two procedures. "If for example the surgeon performs a hammertoe correction on the right 2nd toe and only an open flexor tenotomy on the right 3rd toe I would report 28285-T6 for the hammertoe and 28232-T7 for the flexor tenotomy," says Woodward. "Use of the T modifiers should define the separate nature of the procedures.  There are however payors who either do not recognize the T modifiers or who require reporting of both the 59 and the T modifier."

"Payers will deny the bundled code even when the appropriate location identifying modifier is appended showing that the procedures were performed at different anatomic sites. You should check payer guidelines to see if they require modifier 59 on code 28232 in this scenario," says Stout.