Orthopedic Coding Alert

When bunionectomies and hammertoes are billed together, there can often be problems getting paid. Annette Grady, CPC, CPC-H, coding and reimbursement coordinator at the Bone and Joint Center of Excellence and a member of the National Advisory Board of the American Academy of Professional Coders, explains the difference between these two practices:

A bunionectomy is a procedure performed when a bone in the foot has been moved out of position and must be realigned. Part of the bone is generally removed, and the insertion of Hemi implants (pins) is optional. A hammertoe is done to correct a toe deformity wherein the toe appears mashed and bent downward and must be straightened. Small parts of the bones in the hammertoe are also removed, and pins are sometimes used in this operation, as well. Its not unusual for both procedures to be conducted at the same time.

Using the Toe Modifiers

Medicare and most insurance companies accept the HCPCS modifiers, which must be used to indicate that each procedure was performed on a separate toe, says Ruby OBrochta-Woodward, BSN, RN, ONC, CPC, CCS-P, orthopedic coding consultant, of Minneapolis, MN.

Tina Rud, surgical specialist, Twin City Orthopedics, also of Minneapolis, MN, offers this scenario: Lets say youre performing a bunionectomy called the Mitchell Chevron Procedure (28296) on the great toe of the left foot. You should add the -TA (great toe) modifier to the procedure code to indicate precisely what you have done. Then, on the hammertoe (28285), which, in this example, is the toe right next to it, you should attach the -T1 (left foot, second digit) modifier and attach the -51 modifier (multiple procedures) to show that youre doing separate procedures on different extremities.

OBrochta-Woodward advises that if you have had difficulties, you should check your CCI (Correct Coding Initiative) manual via Medicare and also the American Academy of Orthopaedic Surgeons Global Service Status to see that there is no cross-referencing between the two codes youve chosen. In general, for most of the hammertoe codes, there is no crossover, except for one code, 28270 (capsulotomy; metatarsophalangeal joint, with or without tenorrhaphy, each joint, separate procedure). If this code is used at the same time as a bunion procedure, it will usually get kicked back.

OBrochta-Woodward adds, If a surgeon has done a capsulotomy with the tenotomy at the MP joint at the time that he or she does a hammertoe procedure and a bunion procedure should probably use a modifier -59, indicating that in this case the procedure was performed through a separate incision for a separate problem. You should also use the toe modifiers to further indicate that.

In summation, OBrochta-Woodward says, Coding for these two separately is perfectly allowable so long as the hammertoe procedure is not being done on the bunion joint.

Note: The effect of adding the -59 modifier to the secondary procedure is to unbundle the two procedures in the global period, overriding the automatic edits of private payers and Medicares CCI edits. Because of its unbundling capacity, -59 can be a red flag for medical review; if used incorrectly it can lead to an audit or worse. When another already established modifier is appropriate, it should be used rather than modifier -59. Only if no other descriptive modifier is acceptable, and modifier -59 best explains the circumstances, should modifier -59 be used.

Tip: Some private payers dont read modifiers, so check with your local carrier.