Pathology/Lab Coding Alert

Answer:The answer depends on exactly what specimen the pathologist receives, based on what procedure the surgeon performs.

 

The term “transmetatarsal” most accurately refers to an amputation of the entire forefoot by cutting across (trans) all of the metatarsal bones. If the surgeon performs a transmetatarsal foot amputation (28805, Amputation, foot; transmetatarsal), the appropriate code for the pathologist’s exam depends on whether the reason for the procedure is traumatic or non-traumatic (such as due to diabetic neuropathy and gangrene). Here are your code choices for the pathology examination of a transmetatarsal foot amputation:

Toe is different: The surgeon might amputate a single toe including the metatarsal bone using a procedure such as 28810 (Amputation, metatarsal, with toe, single). In that case, the most accurate coding for the pathology specimen exam would be one of the following codes:

Do this: Make sure the pathology report accurately documents the specimen to justify your code choice. An auditor may find the term, “transmetatarsal amputation” a little ambiguous, so make sure you have documentation regarding whether the specimen is a foot or a toe amputation so that you can support your pathology exam code selection.