Podiatry Coding & Billing Alert

Question: I received an op note from my podiatrist, supposedly for a plantar fasciectomy for plantar fasciitis. The op note read, "The plantar fascia was identified, and the medial band of the plantar fascia was transected using a #15 surgical blade down through but not into the underlying muscle belly. The tension in the medial longitudinal arch then seemed to relax. The area was flushed, and the skin was closed with 3-0 prolenehorizontal mattress sutures." Nothing was marked as a discarded specimen, according to the nurse's intraoperative report, so I don't think the procedure involves an "excision." How should I report it?

Answer: The op note describes an incision, so 28008 (Fasciotomy, foot and/or toe) is the appropriate code. When a physician performs an excision, he would cut body tissue and remove a section of it as well. On the other hand, an incision is only a cut into the body tissue.

Unless you see evidence of a discarded specimen and details of an excision procedure in the op report, you should not report it as such. Make sure you read the entire note, and get clarification from the podiatrist if needed.