Podiatry Coding & Billing Alert

Question: The podiatrist sees an established patient with an obvious left foot and ankle injury, but no diagnosis. After an encounter that includes a detailed history, detailed examination, and medical decision making of moderate complexity, the podiatrist decided to perform closed treatment of a talus fracture with manipulation. Which CPT® codes should we report?

Ohio Subscriber

Answer: You should report 28435 (Closed treatment of talus fracture; with manipulation) for the surgery. Don’t forget to append modifier LT (Left side) to 28435 to indicate laterality, if your payer requires it. Also, you would report 99214 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: a detailed history; a detailed examination; medical decision making of moderate complexity … ) for the evaluation and management (E/M) service with modifier 57 (Decision for surgery) appended to 99214 to show that the E/M and the surgery were separate services.