Podiatry Coding & Billing Alert

Don't let a lack of solid documentation for tumor removal lead you to the wrong code. Test your resection versus excision savvy with this operative report.

Diagnosis: Heterotrophic bone due to Charcot foot deformity.

Procedure: Resection of heterotrophic bone.A straight linear incision was made centering overthe retro bony protuberance. The incision was carried through the sub-q tissues. A soft tissue tunnel was created just inferior to the periosteal covering of the bone from the midfoot and plantar fat pad. The large palpable protuberance of bone was visualized and then resected using a combination of osteotome mallet and power sagittal saw. A separate bone was contoured with very sharp bony protuberance and rasped smooth. The incision was reapproximated with sutures.

Question: Does the documentation support 28171 (Radical resection of tumor; tarsal [except talus or calcaneus]) or 28104 (Excision or curettage of bone cyst or benign tumor, tarsal or metatarsal, except talus or calcaneus)? As far as "the separate bone that was contoured and rasped smooth," would you code that separately?

Since the procedure was similar to treating an exostosis, 28104 seems to be the best choice, says Deb Carr, CCS, a coder with a private billing company who resides in Sunbury, Pa. "I am looking at this as an excision off the bone." The documentation is not indicating that the podiatrist split the periosteum or repaired the periosteum at the end of the case. On the other hand, he treated a protuberance of bone, and the protuberance originated from something, says Carr.

"This op report is missing so much information that it is difficult to code anything," comments Arnold Beresh, DPM, CPC, of Peninsula Foot and Ankle Specialists PLC in Hampton, Va. "There is no mention of a tumor [and] it does not mention what bones where worked on."

With no mention of tumor, 28171 is an unlikely solution, says Carr. Heterotrophic bone diagnosis in conjunction with Charcot normally involves soft tissue aberrant bone.

The podiatrist in the case study, however, seems to be describing something different in his op report. Because the op report states midfoot, "I picked metatarsal as the site of the excision," explains Carr. "I ended up coding it 28104."

"I agree with 28104," comments Anthony Poggio, DPM, in Alameda, Calif. The perisosteum repair (or not) would be included in the allowance for the bone removal and not payable separately. Similarly any "rasping" or "contouring" would also be included in the exostectomy code, Poggio states.

Caveat: You'll want to pinpoint this complex diagnosis in addition to considering the best CPT code. In addition to the 713.5 (Arthropathy associated with neurological disorders) for Charcot foot, "I coded the heterotrophic bone as exostosis, 726.91 (Exostosis of unspecified site),since the research I did on heterotrophic bone did not coincide with what was on the op report," says Carr. Don't forget to also include the underlying disorder for Charcot foot, for instance 250.xx (Diabetes mellitus).

Unfortunately, using 28104 for this case may be undercoding, says Paul Fehring, owner of Drs. Billing Inc., a podiatry-specific billing service in Fairfield, Ohio.

CPT 28171 describes a "radical resection" and has more relative value units (RVUs) at 22.54, while 28104, excising a bone cyst or benign tumor, carries just 12.68 RVUs.

The notes are vague, but it sounds like the podiatrist took out a "fairly large mass" and the work is a bit complicated, Fehring notes. The op note, however, requires more details, Fehring says, such as exactly which bones were worked on and the precise location of the mass. If you could be sure that the bones worked on were not the talus or calcaneus, 28171 may be the correct choice, Fehring says.

To code 28171, you would also need a pathology report stating that the mass the podiatrist removed was in fact a tumor, benign or otherwise, adds Poggio. The op note should also define what "radical" means, Poggio says, for instance, "was one-quarter of the bone removed? Onehalf? Three-quarters?"

"If nothing else, this op report can also be a reminder to the docs to give good documentation," comments Carr. "We coders have to read between the lines more often than we'd like to." Working for a billing company, I "do not have access to the docs to ask them questions about their documentation," says Carr, "if it's really poor documentation we ask for an addendum."

An op report, says Beresh, should have at the minimum the following items:

• patient name
• surgeon(s) name(s)
• anesthesiologist or certified registered nurse
• anesthetist (CRNA) name
• type of anesthesia
• pre-op diagnosis
• final diagnosis
• procedure(s) performed.

Within the op report, the physician should also note that he took time out to identify the patient, the extremity the procedure was to be performed on, the procedure to be performed, and the type of pre-op antibiotic, continues Beresh.

Additionally, the report should include other details, adds Beresh, such as:

• abnormal anatomy
• step-by-step procedure performed
• which bones, tendons, etc. were involved
• type of fixation used (manufacturer, diameter, length), if any
• type of hemostasis used (if a tourniquet, where placed and for how long),
• and amount of blood loss during the procedure.