Orthopedic Coding Alert

"When the excision of a heel spur is complicated by associated conditions, comprehensive documentation
of those conditions and the added procedures and supplies needed to treat them will lead to appropriate reimbursement.

The coding for the removal of a heel (calcaneus) spur [see box on page 5] is uncomplicated. Code 28119 (ostectomy, calcaneus for spur, with or without plantar fascial release) serves if a bona fide spur is eliminated. (The code applies whether or not the procedure also includes an effort to release stress on an irritated plantar fascia with [simple] incisions on either side of the ligamenti.e. fasciotomy.) If a piece of the calcaneus is removed instead of a spur, the procedure is coded 28118 (ostectomy, calcaneus).

But a precise code for a procedure does not mean all possible coding opportunities have been exhausted. A closer look at heel excision illustrates the point.

What Else Can be Billed?

The 28000 procedure codes include dressings or casts applied at the time of surgery. The hospital bills for the DME (durable medical equipment), with one exception. If the physician takes a boot from the office for use in the operating room, the physician can bill for it, explains Pat Yarborough, CPC, an independent coding consultant with R& R Specialists in Charlotte, N.C. Other coders agree.

We often take our own Unna boot to the operating room, says Robin Owens, CPC, a coding specialist, also in Charlotte, N.C. She says, Normally, a walking cast is applied at the time of surgery. It's routine in our practice. It is very rarely after-the-fact [that the walking cast is applied].

If the cast is damaged and must be reapplied in the office, it can be billed. Of course, you can't bill the office visit, which will still be under the global, Owens says.

If a truly unusual circumstance necessitates the change of a cast, it should be reported with a -22 modifier (unusual procedural services). Otherwise, a change during the global period requires a new diagnosis code, such as a pressure ulcer due to the cast707.0 (decubitus ulcer, an ulcer of the skin caused by prolonged pressure). The cast change also should be coded (V53.7).

Note: See page 93 of the December 1999 Orthopedic Coding Alert for the article Getting Reimbursed for Applying Casts and Splints.

When the Physician Bills for Supplies

When a physician applies a new cast for medical reasons, or in rare instances, puts the first cast on in the office, a variety of miscellaneous supplies can be charged. For example, tape of all types and sizes can be billed (A4454). So can adhesive remover or solvent, per ounce (A4455).

There are two important things to keep in mind regarding the tape and solvents. Carrier limits on amounts vary almost from carrier to carrier one coder states. And tape and solvent reimbursement requests must be sent to the DME regional carrier (DMERC) for Medicare patients.

Other billable supplies include specialty items, such as fiberglass, and surgical dressings given to patients for home care. Again, DMERC submission requirements are in effect for Medicare patients.

Treatment for Related Conditions

Microtrauma is the immediate culprit behind the fraying of the plantar fascia. Activity or the form of the feet (e.g., excessive pronation or flat feet) can produce the trauma. Once the plantar fascia tears, degeneration of collagen and angiofibroblastic hyperplasia begin.

Plantar fasciitis itself can be treated with exercise, orthotic devices, drugs or surgery. For example, many orthopedic surgeons look for improvement in this condition if a patient follows a course of weight loss, exercise (to strengthen the tibial muscle and take some of the burden off the foot ligament), and orthotic support.

Many carriers allow for billing of orthotic devices. HCPCS L3480 (heel, pad and depression for spur) and L3485 (heel, pad, removable for spur), as well as heel elevators E0370 (air pressure elevator for heel), are examples. But carrier discretion varies widely for the L and E codes.

If the exercise and shoe modifications do not alleviate the pain, a physician sometimes tries to eliminate the irritation that is caused by inflammation, with cortico-steroids. Do not overlook the corresponding J code if an injection is given in the physician's office.

In one last effort to treat plantar fasciitis without surgery, a physician might try to apply a walking cast or fiberglass ankle brace in the office to relieve stress on the ligament. Codes in the 29000 series apply here. Code 29425 (application of short leg cast, below knee to toes, walking or ambulatory type) or 29515 (application of short leg splint, calf to foot) would apply, depending on the device selected.

When a surgical intervention for plantar fasciitis does not include the removal of a calcaneus spur, unique codes apply. For partial resection of the plantar fascia, 28060 (fasciectomy, plantar fascia; partial [separate procedure]) applies. For complete resection, the choice is 28062 (fasciectomy; plantar fascia; radical [separate procedure]).

Note: A fasciotomy, a simpler procedure than fasciectomy, in which incisions are made to release stress, is coded with 28008, (fasciotomy, foot and/or toe), when done as a separate procedure.

Calcaneal Stress Fractures

A calcaneal stress fracture (825.0) causes pain similar to calcaneal spur and plantar fasciitis. Six to eight weeks in a walker or a short-leg walking cast is the most common treatment.

For a stress fracture, the cast many be applied without a preceding restorative treatment or procedure. The goal is simply to protect, stabilize and comfort the patient. In such a case, 29425 applies to the short-leg walking cast.

However, restorative treatment and casting of calcaneal fractures are coded using 28400, 28405, 28406, 28415 and 28420, depending on the degree of surgical interventionwhether there is manipulation, bone grafting, etc.

Remember the Global Components for the 28000

Anything in the 28000 series includes casting or compression dressing, whichever the surgeon uses, says Adrienne Rabinowitz, CPC, a coder at an orthopedic facility in New Jersey. The first cast applied at the time of surgery is always part of the procedure.

Whether one is applied at the time of the procedure or one is deemed necessary some time later, it can be billed separately. Obviously, there must be a medical necessity for the cast, says Rabinowitz.

Rabinowitz points out that one thing coders might overlook, and should not, is the opportunity to code for reimbursement for devices that are added after a cast is appliedwhether the cast was put in place during surgery or later. For example, adding a walker is billable under 29440 (adding walker to previously applied cast).

Although casting for excision of calcaneal spur and resection for plantar fasciitis will almost always be done at the time of the surgical procedure, there are instances when a cast cannot be applied in the operating room. Excessive swelling would be one reason for a waiting period, explains coding consultant Yarborough.

She recommends using a -24 modifier (unrelated evaluation and management service by the same physician during a postoperative period) to report the application of a cast in the physician's office during the postoperative period. The cast put on in the office can be billed separately.

Origin of Calcaneal Spur The plantar fascia is the wide band of tissuea ligamentthat runs along the bottom of the foot from the heel bone (calcaneus) to the toe bones (metatarsals). It makes running and stretching (e.g." to reach a high shelf) possible. Irritation of the plantar fascia causes some painful problems. And the problems are often lumped together by the generic terminology heel spur. Medically a heel spur is synonymous only with a calcaneal spur (726.73). It typically results from progressive worsening of a condition that begins with repetitive excessive use or a tearing (microtrauma) at the site of the plantar fascia origin on the calcaneus. The initial irritation of the plantar fascia signals a degenerative condition plantar fasciitis (728.71). If the plantar fascia pulls away from the calcaneus and the condition is not corrected calcium deposits form on the calcaneus. The deposits constitute a protrusion (exostosis) or heel spur. The exostosis extends from the weight bearing part of the calcaneus forward. Radiography shows that about 45 percent of patients who suffer from plantar fasciitis also suffer from a calcaneal spur. When the conditions coexist the question of which condition causes the pain and which should be treated does not always have physicians in agreement. (Some orthopedic surgeons argue that a foot adapts to a calcaneal spur and only the incipient spur is painful.)

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