Podiatry Coding & Billing Alert

If coding for fracture and E/M combo visit, don’t forget modifier 57.

Do you know which CPT^® codes to turn to when reporting talus and calcaneal fracture repairs? Although the talus and calcaneus are very anatomically close to each other, they are considered two different parts of the body.

Read on to learn more about these injuries and how to best code them.

Tip 1: Differentiate Between Calcaneal and Talus Fractures

You must know the difference between calcaneal from talus fractures, to report the correct CPT^® repair codes.

“The calcaneus is located at the bottom of the foot and part of the heel,” explains Peggy Stilley, CPC, CPC-I, CPMA, CPB, COGBC, revenue integrity auditor for Oklahoma Sports Orthopedics Institute in Norman. “The talus sits above the calcaneus and at the bottom of the ankle joint.”

When the patient fractures both the talus and the calcaneus, this is defined as a hindfoot fracture.

“Both the talus and the calcaneus are critical to the ability to walk,” Stilley continues. “Calcaneus fractures are the most common, while talus fractures are more difficult to heal due to the weak blood supply of the talus.”

Tip 2: Look for These Fractures on Trauma Patients

You’re unlikely to see someone with a calcaneal or talus fracture that was the result of minor injury, like from stepping off the curb wrong. Instead, these fractures are typically the result of major foot and ankle injuries.

“Fractures of the talus are typically the result of trauma,” Stilley explains. “High-impact falls or motor vehicle accidents are common causes. With greater impact, one typically finds greater damage.”

Lynn M. Anderanin, CPC, CPMA, CPPM, CPC-I, COSC, senior director of coding education at Healthcare Information Services in Park Ridge, Illinois, adds to Stilley’s description: “Patients with these type of fractures normally have had a strong force to their ankle causing the bones to break. This is common in people who land on their feet falling from a height or impact to the foot in a car accident.”

Tip 3: Carefully Choose Correct Repair Code

Once you know the anatomic location of the injury, it’s time to choose a code for the calcaneal/talus fracture. According to Anderanin, these surgeries can include “closed treatment, with or without manipulation, percutaneous or open treatment, and bone grafting on either kind of fracture.”

Calcaneal fracture repairs: You’ll choose from one of the following codes for calcaneal repairs, depending on encounter specifics:

• 28400 (Closed treatment of calcaneal fracture; without manipulation)
• 28405 (… with manipulation)
• 28406 (Percutaneous skeletal fixation of calcaneal fracture, with manipulation)
• 28415 (Open treatment of calcaneal fracture, includes internal fixation, when performed)
• 28420 (… with primary iliac or other autogenous bone graft (includes obtaining graft).

Talus fracture repairs: For talus fractures, you would turn to these codes:

• 28430 (Closed treatment of talus fracture; without manipulation)
• 28435 (… with manipulation)
• 28436 (Percutaneous skeletal fixation of talus fracture, with manipulation)
• 28445 (Open treatment of talus fracture, includes internal fixation, when performed)
• 29892 (Arthroscopically aided repair of large osteochondritis dissecans lesion, talar dome fracture, or tibial plafond fracture, with or without internal fixation (includes arthroscopy).

Tip 4: Approach Combo Encounters With Caution

So, how would you handle a situation where the podiatrist fixes both a calcaneal and talus fracture?

According to the National Correct Coding Initiative (CCI), these two procedures are not bundled. However, this doesn’t always mean you should report two codes.

Calcaneal and talus fracture repairs “do not bundle,” Stilley says. It has been Stilley’s experience; however, that “location of the calcaneal fracture can determine if both codes are billable. If the calcaneal fracture is located at the posterior portion calcaneus and separate incisions are required to treat the fractures,” you might be able to report two fracture codes, she continues.

“If the calcaneal fracture is just below the talus fracture and accessed through the same incision, it could be argued these would be bundled,” Stilley says.

“Following NCCI guidelines, if you are treating at least one fracture without manipulation, that would not be reported if you are treating the other also,” Anderanin explains.

Best bet: Check your individual payer contracts on calcaneal and talus fracture surgeries during the same session and file the claim however the payer wants it.

Tip 5: Utilize Modifier 57 For Fracture and E/M Visits

Sometimes the podiatrist may perform an evaluation and management (E/M) service separate from the talus/calcaneal fracture repair. When you can prove the key elements of a significant, separately identifiable E/M service, you should be able to report it in addition to the surgery code.

If you do end up coding for a separate E/M service related to a talus/calcaneal fracture repair, be sure to use modifier 57 (Decision for surgery) on the E/M code, not modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service).

Reason: All of the calcaneal/talus fracture surgeries addressed in this article have 90 global surgical days, which makes them major procedures and subject to modifier 57 on separate E/Ms (surgeries with global surgical days of 0 or 10 days are modifier 25 eligible.)