Podiatry Coding & Billing Alert

Question: The podiatrist made an incision in the patient’s right foot over the targeted area. He deepened the incision to reach the first metatarsal bone. He then used an osteotome to remove the bunion from the patient’s right foot. He made an osteotomy through the metatarsal away from a structure’s point of attachment and removed a small wedge of bone. He realigned the bones in a more appropriate position and used fixation devices to maintain that positioning. Also, during this procedure, the podiatrist performed a sesamoidectomy. Which CPT^® code should I report for this procedure? And what is the correct ICD-10 code?

Hawaii Subscriber

Answer: You should report 28296 (Correction, hallux valgus (bunionectomy), with sesamoidectomy, when performed; with distal metatarsal osteotomy, any method) for this procedure. The diagnosis code you should link to 28296 is M21.611 (Bunion of right foot).

Delve deeper into 28296: Code 28296 “includes the removal of prominent or hypertrophied bone from the medial aspect of the first metatarsal head (distal metaphysis) along with distal first metatarsal osteotomy, and may additionally include the resection of excess bone at the dorsomedial, dorsal, and/or dorsolateral aspect of the metatarsal head, and/or base of the proximal phalanx with or without related soft-tissue correction, resection, or release, according to CPT^® Assistant.

Code 28296, which CPT^® Assistant calls the “most commonly performed bunionectomy procedure,” may also include tendon and other soft-tissue balancing and/or removal of one or both sesamoids.

Podiatrists usually perform a 28296 service “to correct a mild-to-moderate hallux abductovalgus deformity associated with a mild-to-moderate intermetatarsal angle (metatarsus primus varus [adductus]) and/or distal lateral torsional deviation of the metatarsal head,” CPT^® Assistant explains.