Podiatry Coding & Billing Alert

Neglecting to report multiple fractures could cost you $500 per metatarsal.

Lisfranc joint injuries can pop up in just about any patient, from athletes to the elderly.

Scoop up all of the multiple repair payments you've earned and learn when accurate modifiers can boost revenue with this inside look at Lisfranc repair coding.

ICD-9: Diagnosis coding depends on whether the Lisfranc injury involves an open or closed fracture, or an open or closed dislocation, or a combination thereof. The coding options are:

• 825.25 -- Fracture of metatarsal bone(s) closed
• 825.29 -- Fracture of tarsal and metatarsal bones, closed; Other
• 825.35 -- Fracture of metatarsal bone(s), open
• 825.39 -- Fracture of tarsal and metatarsal bones, open; Other
• 838.03 -- Closed dislocation of tarsometatarsal joint
• 838.13 -- Open dislocation of tarsometatarsal joint.

1: Code for Each Fracture Repair

Don't forget to treat a repair to each fractured metatarsal bone as one unit.

When the podiatrist uses the common open reduction internal fixation (ORIF) technique to repair a fracture to the Lisfranc area, report 28485 (Open treatment of metatarsal fracture, includes internal fixation, when performed, each).

Don't miss: Code one unit or 28485 for each metatarsal fracture, advises Peter Koukounas, president of Hippocratic Solutions, LLC, a podiatry-specific billing service based in Clifton, N.J.

Based on the anatomy, you would typically report three units of 28485, notes Richard Odom, DPM, ABPS, CPC, a practicing podiatrist at Gulf Coast VA Hospital System in Mobile, Ala.

Append modifier 59 (Distinct procedural service) to 28485 starting with the second line item.

Reimbursement: CPT 28485 carries 13.89 physician work relative value units (RVUs), according to the 2010 Medicare Physician Fee Schedule. That translates to $501.14 per metatarsal based on the updated 2010 national conversion factor of $36.0791.

Careful: Keep in mind that 28485 represents fractures in separate metatarsals, not multiple fractures within the same metatarsals, points out Arnold Beresh, DPM, CPC, of Peninsula Foot and Ankle Specialists PLC in Hampton, Va. If one metatarsal contains multiple fractures, report only one unit of 28485.

2: Report Units for Dislocations

Broken bones aren't the only type of Lisfranc injury -- and many times coders forget to report 838.03 or 838.13 for the dislocation.

In addition to open fracture repair, treatment of dislocated tarsometatarsal joints is one of the most common types of Lisfranc repair, notes Koukounas. Code repair of dislocated Lisfranc joints as 28615 (Open treatment of tarsometatarsal joint dislocation, includes internal fixation, when performed). Most payers will recognize multiple units of 28615 per individual joint that the podiatrist reduces, says Odom.

Check with your payer and append modifier 59 to multiple units as needed. In some cases, a patient may present with both dislocation of the Lisfranc joints and a metatarsal fracture. These are distinct services which represent repair of two separate entities -- a joint and a fracture, notes Beresh. The good news is there are no bundling issues with 28485 and 28615. Append modifier 59 (Distinct procedural service) to 28485 (which is the comprehensive code and the lowered valued of the two codes) when reporting both services, says Koukounas.

3: Count Multiple K-Wire Repairs

In some "low-energy" injuries, the podiatrist may opt out of an open repair and instead proceed with a closed treatment to repair the dislocation via introduction of percutaneous K-wire.

If this is the case, report 28606 (Percutaneous skeletal fixation of tarsometatarsal joint dislocation, with manipulation). If the podiatrist manipulates multiple K-wires to repair multiple joint dislocations, you can list multiple units of 28606 with modifier 59 appended to the subsequent units, says Koukounas.

4: Hold a Place for Bone Fusion

Your podiatrist may take an alternate approach and select arthrodesis, or bone fusion, to repair the injury.

When this is the treatment plan, report 28730 (Arthrodesis, midtarsal or tarsometatarsal, multiple or transverse) to indicate the procedure to fuse the tarsometatarsal joint or midtarsal joint. Report this procedure as a single unit.

While some studies show arthrodesis as more effective, 28485 and 28615 will be your "go-to" codes to repair Lisfranc joint injuries, says Koukounas.