Podiatry Coding & Billing Alert

Question: A 45-year-old patient has been experiencing chronic heel pain for several months. After trying conservative treatments such as rest, physical therapy, and anti-inflammatory medications, the patient had no relief. The patient’s primary care physician referred them to my podiatrist for further evaluation. The podiatrist performed a physical examination and ordered imaging tests, which revealed a heel spur. The heel spur was causing significant discomfort and interfering with the patient’s daily activities. Given the patient’s symptoms and the lack of response to conservative treatments, the podiatrist performed heel spur removal surgery. During the procedure, the podiatrist made an incision in the heel, removed the spur, and repaired the damaged tissue. The patient was moved to recovery and later discharged with instructions for postoperative care and pain management. How should I code for the surgery?

AAPC Forum Participant

Answer: For the heel spur removal, you will use CPT^® code 28119 (Ostectomy, calcaneus; for spur, with or without plantar fascial release). Be sure to check the medical notes to verify that only a heel spur was removed and not a part of the calcaneus. If a part of the calcaneus was removed, you will use code 28118 (Ostectomy, calcaneus) instead. It’s also important to append the LT (Left side) or RT (Right side) modifier to indicate to the payer which foot underwent the surgical procedure. The ICD-10 code for the diagnosis might be M77.31 (Calcaneal spur, right foot) or M77.32 (Calcaneal spur, left foot); again, this will depend on which foot was affected.

“You should look closely at the physician language and anatomy to identify the correct code,” says Jennifer McNamara, CPC, CCS, CRC, CPMA, CDEO, COSC, CGSC, COPC, director of healthcare training and practice support at Healthcare Inspired LLC, in Bella Vista, Arkansas. “For CPT^® code 28119, the documentation should include phrases like ‘incision at the plantar aspect of the foot,’ ‘accessing the fascia,’ and ‘excision of heel spur.’ This indicates the intention behind the procedure was to remove the heel spur. Conversely, if the note includes phrases like ‘the calcaneus is resected,’ it suggests that part of the calcaneus bone was removed, which requires CPT^® code 28118,” she says.