Wiki Coding for multiple bilateral hammertoe 28285

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bharmon518

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Hi there - we have a surgeon who performed a partial amputation of the 3rd LT toe, followed by bone biopsy and a primary closure. He then performed hammertoe corrections on the LT and RT 3rd toes, and hammertoe corrections on the LT and RT 4th toes. I am at a loss of how to bill this to Medicare. 28285 has a bilateral status indicator of 1, but I've usually billed 28285 individually with their respective T modifiers and XS without issue, but most providers don't do two bilateral hammertoes.

Do I bill 28285 individually with XS and the T modifiers? If not and they want a 50 modifier, how to I bill this given he did bilateral hammertoe corrections twice?

Medicare initially split the claim, and the office's biller initially billed Medicare as follows (I think the 51 is inappropriate here):
28820, T2,59,51 (Medicare paid - but I think 28825 is more appropriate per the documentation as he did an amputation at interphalangeal joint.)
28285, T3 (Medicare paid)
28285, T2,51,59 (Medicare paid)
28285, T7,51 (Medicare denied for missing modifier)
28285, T8,51 (Medicare denied for missing modifier)

Thanks in advance!
 
How is this person walking? LoL. I can't believe they did bilateral. Is this op note correct? Hah. Can we see the op redacted? Is it dictated correctly? I would be checking with my surgeon on this. Especially if it veers away from their normal cases.

You are correct, take the 51 modifiers off. Medicare doesn't want 51.

If IP joint amputation 28825. Not 28820, that is MTP. Was it the DIP? It would have to be if a hammertoe was done at the same toe on the PIP. I have never seen this done; this is odd. How/why would they do this on the same toe?

You would not modifier 50.

My opinion: The T modifiers should be enough. That is the point of them, you are indicating the anatomical location/modifier. Make sure the correct dx codes are on each line. *Maybe* an X to show the 28825 was at the DIP and the 28285 on the same toe was PIP, but I don't even know if you need that either. Run it through your edit checker/encoder like this - it's clean.

28285-T2
28285-T3
28285-T7
28285-T8
28825-T2

p.s. that biller needs more training or not to be doing multi-line foot and ankle cases. :) :) :)
 
I know it's unusual. Dr was planning on doing arthrodesis of 3rd bilat toes and the amputation of the LT 3rd toe, but he was admitted to hospital 3 days later w/ a worsening infection of a diabetic ulcer on the LT 3rd toe. He was discharged and able to ambulate in surgical shoes and a walker to tolerance but was to remain NWB as much as possible.

When I run the codes through the Codify claim scrubber, it tells me to bill a 50 on 28285 if performed bilaterally, likely because it's got a 1 Bilat indicator. If Medicare processed the codes with the 59 initially, I'm surprised, but maybe that's the modifier they're missing because they initially denied the other two instances of 28285 billed w/out a 59?

So, Amy I agree, maybe bill by line item and the X where necessary?
 
I did run it through the claim scrubber as follows, and checked Medicare as primary payer, and it advises me "If you are reporting a bilateral procedure, append modifier 50 to 28285" although it says low severity for that issue.

28825.T2 - M86.172
28285.T2 - M20.42
28285.T3 - M20.42
28285.T7 - M20.41
28285.T8 - M20.41
 
bharmon518 said:
I did run it through the claim scrubber as follows, and checked Medicare as primary payer, and it advises me "If you are reporting a bilateral procedure, append modifier 50 to 28285" although it says low severity for that issue.

28825.T2 - M86.172
28285.T2 - M20.42
28285.T3 - M20.42
28285.T7 - M20.41
28285.T8 - M20.41
Click to expand...
I would do it like this with no 50s and no 59s. The Ts are it. There are not NCCI edits against a code and itself and there is no NCCI edit with 28825/28285. 59 not required. If it still kicks out you might need X.
 
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