Podiatry Coding & Billing Alert

Hint: Use of modifier 52 is out of the question.

Does partial sesamoidectomy coding have you scratching your head in confusion? Reporting 28315 alone may not always be your best bet. Follow these three steps to claim success.

Consider the following scenario:

The podiatrist at a practice sees a patient -- with history of chronic sesamoiditis (733.99) of the right metatarsophalangeal joint and hammertoe (right third and fourth toes) -- for hammertoe correction and sesamoid planing of the metatarsophalangeal joint. The operative report indicates that only 40-50 percent of the sesamoid bone was removed. What should you report?

Tip toe through these 3 steps, and onto coding success without much effort.

1. Record Medical Necessity

Cosmetic surgery for the purpose of enhancing the appearance of the foot will not give you coverage in most insurance programs. Support medical necessity with: Appropriate diagnosis code to define persistent symptoms at the right metatarsophalangeal joint and hammertoe. In the above scenario, 733.99 best fits the symptoms exuded by the patient;

At least 6 months of conservative therapy, for example, shoe modifications, padding or other accommodative devices, corticosteroid injections, nonsteroidal anti-inflammatory drug therapy, physical therapy, or activity modifications; Physical exam and x-ray findings, which may vary by carrier.

2. Check for Repair Code Series and T Modifiers

Because the podiatrist is doing repair/revision on two of the patient's right toes, you should bill twice using 28285 (Correction, hammertoe [e.g., interphalangeal fusion, partial or total phalangectomy]), and 28315 (Sesamoidectomy, first toe [separate procedure]) for the removal of a sesamoid bone performed. Don't forget to append proper T modifiers.

Quick Fact: Hammertoes are of two kinds -- both of which are billable using 28285, says Walter J. Pedowitz, MD, CPT Advisory Committee Member for the American Orthopaedic Foot and Ankle Society in an Orhopedic Coding Alert article. Flexible hammertoes can be diagnosed and treated while still in the developmental stage, so podiatrists consider it less serious. Not to mention, flexible hammertoes are still  moveable at the joint. On the other hand, rigid hammertoes are more serious, and canoccur in patients with severe arthritis. In this type, the tendons have become tight and the joint misaligned and immobile. The only possible way to treat patients with rigid hammertoes is through surgery. "The cartilage on the base of the middle phalanx is roughened up to promote arthrofibrosis, and the complex is then straightened and fixed with a K-wire," explains Pedowitz.

Your billing for the scenario given should look like this:

• 28285-T7, referring to the third right toe;
• 28285-T8, referring to the fourth right toe;
• 28315-RT, referring to the right hallux.

"You would probably use the RT modifier with 28315, and not the T5 modifier unless this is an interphalangeal sesamoid of the first toe and not a sesamoid under the 1sr metatarsal head," notes Arnold Beresh, DPM, CPC, of Peninsula Foot and Ankle Specialists PLC in Hampton, Va., referring to the last line of what your report should look like.

Using modifiers is important to correctly identify various separate procedures, as in the case of foot surgery, which usually requires the use of multiple codes because your podiatrist can perform can perform forefoot, midfoot, and hindfoot procedures in one session.

T modifiers are classified level II by HCPCS, and are used to identify surgery performed on specific toes. TA is used for the left hallux, T1 for the second left, T2 for the third left, T3 for the fourth left, T4 for the fifth left, T5 for the right hallux, T6 for the second right, T7 for the third right, T8 for the fourth right, and T9 for the fifth right.

Caution: You must never use modifier 52 (Reduced services) with 28315 even when the podiatrist removes only a part of the sesamoid bone. Rationale: The time and effort to remove a portion of the sesamoid is about the same as a sesamoidectomy.

You should always check your CPT manual to discern if you have a more appropriate choice before you append 52, reminds Catherine Brink, CMM, CPC, president of Healthcare Resource Management Inc. in Spring Lake, N.J.

Optional: In some cases, payers require modifier 59 (Distinct procedural service) on the second and all subsequent procedures if only to indicate that the service  was distinct or independent from other services performed on the same day. However, CMS discourages using modifier 59 carelessly. "When another already established modifier is appropriate, it should be used rather than modifier 59. Only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used," according to a National Correct Coding Initiative (NCCI) article.

3. Look Out for Postoperative Services

If you're going to report postoperative services, you must report it accurately. Sesamoidectomy and correction of hammertoes classify as major surgical procedures with 90- day global periods. This means that you should not report separately any postoperative fixation (e.g., splint, toe strapping, wires) applied during the global period.

Complication: In case an implant gets infected, the podiatrist would surgically remove it. This would constitute a medically necessary procedure that you'd report as 20680 (Removal of implant; deep, ([e.g., buried wire, pin, screw, metal band, nail, rod or plate]) to report your claim. Append modifier 78 (Unplanned return to the operating/procedure room by the same physician following initial procedure for a related procedure during the postoperative period) to 20680 if the implant is removed within the surgical global period.