Orthopedic Coding Alert

Question: One of our physicians is trying to bill for a bunionectomy with 28292 (Correction, hallux valgus [bunion], with or without sesamoidectomy; Keller, McBride, or Mayo type procedure) and an osteotomy using 28306 (Osteotomy, with or without lengthening, shortening or angular correct, metatarsal; first metatarsal) on the same big toe. She asked us to append modifier 59 (Distinct procedural service) to 28306 so the payer would reimburse us for both, but we aren’t sure if this is accurate advice. Can you advise?

Answer: Unfortunately, the answer may depend on the payer, because CPT and Medicare tend to disagree on this issue. CPT says that when a McBride hallux valgus correction is performed with a proximal first metatarsal osteotomy, you can report both 28292 and 28306-59, so you can go that route if your insurer sticks to the CPT guidelines.

If your payer follows National Correct Coding Initiative (NCCI) edits, however, you should instead report 28296 (Correction, hallux valgus [bunion], with or without sesamoidectomy; with metatarsal osteotomy [eg, Mitchell, Chevron, or concentric type procedures]) because it says “with osteotomy.” This is the case for Medicare and any other insurers that follow the NCCI.

Keep in mind that if the surgeon used a nerve block prior to performing the procedure, that is bundled into the surgery. NCCI precludes you from reporting 64450 (Injection, anesthetic agent; other peripheral nerve or branch) with 28296 if the nerve block is being used for the bunionectomy.