Podiatry Coding & Billing Alert

Question: The podiatrist performed a level-three evaluation and management (E/M) service for an established patient. The podiatrist then performed a partial phalangeal base resection on a patient’s right great toe and a complete resection on a patient’s right second digit. Which codes should I report on this claim?

Florida Subscriber

Answer: You should report the following codes on this claim:

• 28126 (Resection, partial or complete, phalangeal base, each toe) for the great toe resection. Modifier alert: Append modifier T5 (Right foot, great toe) to 28126 to indicate the anatomy of the injury and treatment.
• Report 28126 again for the second digit resection. Modifier alert: Append modifier T6 (Right foot, second digit) to 28126 to indicate the anatomy of the injury and treatment.
• Report 99213 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: an expanded problem focused history; an expanded problem focused examination; medical decision making of low complexity …) for the E/M service. Modifier alert: Append modifier 57 (Decision for surgery) to 99213 to show that the provider performed a separate E/M prior to the phalangeal base resections.