Podiatry Coding & Billing Alert

Question: I am having difficulty coding an OP report. The preoperative and postoperative diagnosis are the same: gas gangrene of the left foot. The procedure performed was amputation of the left fifth digit and the mid and distal half of the fifth metatarsal. Would I code this as 785.4; 28810-T4?

Utah Subscriber

Answer: You are correct on using 28810 (Amputation, metatarsal, with toe, single). But, you should also append modifier 52 (Reduced services) since the surgeon removed only the distal half of the metatarsal. You would also append modifier LT (Left side [used to identify procedures performed on the left side of the body]) to designate the left foot. Please also note that payment modifiers are always listed before informational modifiers. You would not use T4 modifier (Left foot, fifth digit) since digit modifiers designate phalanges only and the surgeon amputated at the level of the metatarsal. The provider stated gas gangrene, so the diagnosis code 040.0 (Gas gangrene) would be the appropriate diagnosis; not 785.4 (Gangrene).

So, the final coding would look like this: 28810- 52-LT and DX: 040.0