Orthopedic Coding Alert

The answer may surprise you

Your foot surgeon performs a hammertoe correction and flexor tenotomy on a patient's interphalangeal joint. The National Correct Coding Initiative (NCCI) doesn't bundle the two services together, so you are free to report both 28285 and 28232 on your claim, right? Not so fast. The NCCI may not bundle the codes, but you can't always report them together.

Physicians use the term "hammer toe" (735.4) to describe a variety of lesser toe (toes two-five) deformities, as follows:
 

Mild deformity: Hyperflexion of distal toe without fixed contracture at MP or PIP joint

Moderate deformity: Fixed or partially fixed contracture at PIP joint with mild extension contracture at MP joint

Severe deformity: Fixed flexion contracture at PIP joint and fixed extension contracture of MP joint (or subluxation/dislocation) of base of proximal phalanx on MT head.

Orthopedic surgeons who perform hammertoe corrections (28285, Correction, hammertoe [e.g., interpha-langeal fusion, partial or total phalangectomy]) occasionally also perform flexor tenotomy on the same toe and report 28232 (Tenotomy, open, tendon flexor; toe, single tendon [separate procedure]). Follow our expert advice to determine whether you should report the tenotomy or include it in the hammertoe correction.

Separate Incision May Not Warrant Separate Code

History: "Since foot surgeons don't always perform tenotomy with hammertoe corrections, some practices will report the tenotomy separately from their hammertoe code, arguing that the tenotomy is not a 'standard' procedure to perform with hammertoe correction," says Ken Robertson, an independent coder who bills for four orthopedic surgeons and three foot surgeons in Atlanta. "The American Academy of Orthopaedic Surgeons' (AAOS) Complete Global Service Data for Orthopaedic Surgery doesn't list 28232 as a component of the hammertoe correction, and the NCCI doesn't bundle the codes together, which sort of confirms for some coders that it's OK to report both codes together."

Reality: Correcting a hammertoe clinically includes the flexor tenotomy, even if the AAOS and the NCCI don't formally bundle the codes. "Tenotomizing the flexor tendon at the interphalangeal joint to correct a hammertoe contracture is included in the hammertoe correction procedure," says Harry Goldsmith, DPM, CEO of Codingline.

Include Skin Release in Hammertoe Payment

"While some surgeons may opt to make another incision plantarly when performing a hammertoe correction, many just look in the void where the proximal phalanx head used to be, see the tendon staring up at them, and tenotomize it without another incision on a toe," Goldsmith says. Whether or not your physician performs the procedure through a separate incision, you should include the tenoto-my as a component of the hammertoe allowance, Goldsmith says.

Different Toes? Report 2 Codes

If your surgeon performs hammertoe corrections on several toes, enter a separate code listing for each digit on separate lines on the claim form, and append the toe modifiers as follows:
 

28285-T8 -- Right foot, fourth digit

28285-T6 -- Right foot, second digit.

"If you code this way, you won't confuse insurers as much as if you attach multiple modifiers to the same code (for instance, 28285-T8, -T6)," Robertson says.

If your surgeon performs flexor tenotomy on one toe and a hammertoe correction on a separate toe, you should report both 28285 and 28232 with the toe modifiers appended, Robertson says. If your payer does not recognize the toe modifiers, you should append modifier -59 (Distinct procedural service) to 28232.