Podiatry Coding & Billing Alert

Question: Our physicianperformed hammer toe corrections on 2nd, 3rd, 4th, and 5th toes. The physician documentation states,“right great toe mallet deformity correction. I used a dorsal incision that was longitudinal over the great toe. I exposed the joint and removed some of the joint capsule and made an extensor tenotomy. I made a cut at the middle phalanx and distal phalanx, and then anchored this in place with a single K-wire. A 4.0 cannulated screw was used to anchor this into place. I closed.” Is 28285 the right CPT® code? Would the diagnosis code of735.8 be appropriate or 735.4?

Alabama Subscriber

Answer: No. According to the notes provided by you, 28755 (Arthrodesis, great toe; interphalangeal joint) seems more appropriate.

Although code 28285 (Correction, hammertoe [eg, interphalangeal fusion, partial or total phalangectomy]) may appear as the correct CPT® code here for a mallet/hammer deformity correction, your notes describe a more extensive procedure with removal of the joint capsule and fusion of interphalangeal joint (IPJ). 

Code 28755 provides more similarity with the procedure performed. The procedure description on Codify states, “In this procedure, the provider surgically immobilizes the interphalangeal joint of the great toe. An interphalangeal joint is a joint between the two phalanges of the great toe. When the patient is appropriately prepped and anesthetized, the provider makes an incision in the skin over the interphalangeal joint of the great toe. He dissects down through subcutaneous tissue, preserving the nerves and veins. He then retracts the muscle tendon to gain access to the joint to be fused. He next cuts the joint capsule and enters the joint. He first removes all dead or inflamed tissue from the joint cavity. He then brings the bones of the joint in close proximity, or nearness, and fuses the joint using implants like K–wire, screws, or plates.”

For the diagnosis code, the best option is 735.3 (Hallux malleus).