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Commonly Asked Foot and Ankle Coding Questions

Mary LeGrand, RN, MA, CCS-P, CPC

This month’s coding column addresses questions related to coding of foot and ankle procedures.

Metatarsal fracture
Q:
A patient is diagnosed with a metatarsal fracture; the shaft is fractured both proximally and distally. The surgeon treats the fracture of the shaft with an open reduction and internal fixation (ORIF) and internally fixates both fractures as a single unit. I think I should report CPT code 28485 (open treatment of a metatarsal fracture, includes internal fixation, when performed) one time, but I wonder if I should I report the second fracture as 28485-52?

A: You would be correct in reporting CPT code 28485 just once. The code includes the management of both fractured locations of the same metatarsal.

Fig. 1 Preoperative (A) and postoperative (B) radiographs showing restoration of length, alignment, and rotation with ORIF to protect soft tissues, and simplify the pilon fracture for later definitive reconstruction.
Reproduced from Liporace FA, Mehta S, Rhorer AS, Yoon RS, Reilly MC: Staged treatment and associated complications of pilon fractures.
Inst Course Lect 2012; 61:53–70

Osteochondritis dissecans of the talus
Q:
Our foot and ankle surgeons perform surgical procedures for osteochondritis dissecans of the talus in which they excise and drill the defect. The operative note usually indicates that the procedure was performed arthroscopically, but sometimes it appears that the procedure included an open approach. I am familiar with CPT code 29891—Arthroscopy, ankle, surgical, excision of osteochondral defect of talus and/or tibia, including drilling of the defect—for the arthroscopic approach, but how do I code the open procedure?

A: An arthroscopic approach is reported, as noted, with CPT code 29891, but a specific code does not exist for an open approach. However, CPT code 28120—Partial excision (craterization, saucerization, sequestrectomy, or diaphysectomy) bone (eg, osteomyelitis or bossing); talus or calcaneus—describes the work associated with this procedure and would be the correct code to report the open treatment of the osteochondral defect.

Temporizing management of a pilon fracture
Q:
Two surgeons in our practice managed the care of a patient who had a pilon fracture (Fig. 1A). On June 1, 2012, the first surgeon documented in the operative note the following procedure title: “temporizing management of a pilon fracture” and dictated that this was the first stage of a multiple-stage surgery (Fig. 2). I only see the application of an external fixator documented for the first surgery.


Fig. 2
A spanning external fixator can help achieve the initial goals of restoring the mechanical axis and length and stabilizing the bone as the soft-tissue swelling subsides.
Reproduced from Liporace FA, Mehta S, Rhorer AS, Yoon RS, Reilly MC: Staged treatment and associated complications of pilon fractures.
Inst Course Lect 2012; 61:53–70

 

Because the first surgeon was on call, care of the patient was transferred to the foot and ankle surgeon in the practice. On June 10, 2012, the foot and ankle surgeon returned the patient to the operating room. The operative note for the second procedure was “ORIF of the pilon fracture (tibia and fibula) and removal of external fixator” (Fig. 1B). How should I report these two surgeries?

A: Based on the information you provided, you could consider using the following codes. The absolute surgical procedure codes would be based on the documentation in the surgeon’s operative note.

For the first surgical intervention on June 1, the appropriate CPT code would be based on the type of external fixation system used—either CPT code 20690 (application of a uniplane [pins or wires in one plane], unilateral, external fixation system) or CPT code 20692 (application of a multiplane [pins or wires in more than one plane], unilateral, external fixation system [eg, Ilizarov, Monticelli type]). The surgeon should document the type of external fixation system used (uniplane or multiplane) in the operation title.

For the second surgical intervention on June 10, CPT codes 27828-59—open treatment of fracture of weight bearing articular surface/portion of distal tibia (eg, pilon or tibial plafond), with internal fixation, when performed; of both tibia and fibula—and 20694-58, 51—removal, under anesthesia, of external fixation system—would be appropriate.

Mary LeGrand, RN, MA, CCS-P, CPC, is a consultant with KarenZupko & Associates, Inc., who focuses on coding and reimbursement issues in orthopaedic practices. Information in this article has been reviewed by members of the AAOS Coding, Coverage, and Reimbursement Committee.

AAOS Now
August 2012 Issue
http://www.aaos.org/news/aaosnow/aug12/managing1.asp