Podiatry Coding & Billing Alert

Question: I performed a procedure which included an I&D of plantar space infection and partial first ray resection. My thought is to use code CPT^® 28003 for the incision and drainage. Would the amputation of the toe and metatarsal head be included, or is it billable separately (CPT 28810)? The incision was carried to encompass the partial ray resection and the I&D.

New Jersey Subscriber

Answer: If you did not amputate the entire metatarsal, 28110 is not appropriate. Why? The description of CPT^® 28810 reads, “amputation, metatarsal, with toe, single.”

CPT^® code 28003 (Incision and drainage below fascia, with or without tendon sheath involvement, foot; multiple areas) is appropriate for an I&D that is done below the level of fascia in multiple areas. For a partial first ray amputation (hallux and part of the 1st metatarsal), both CPT^® 28820 (Amputation, toe; metatarsophalangeal joint) and CPT^® 28122 (Partial excision [craterization, saucerization, sequestrectomy, or diaphysectomy] bone [e.g., osteomyelitis or bossing]; tarsal or metatarsal bone, except talus or calcaneus) are appropriate. CPT^® 28122 would require a 59 modifier in this scenario.

If the incision portion of your I&D was actually part of the incision to do the partial first ray amputation, then the I&D was a component of the amputation and should not be separately billed.

Conversely, if the I&D was its own distinct procedure or independent from the amputation, then it could be separately billed. In this situation, your documentation should indicate that the I&D was a different procedure or surgery, different site, or a separate incision from the amputation.