Four steps to accurate coding for hammer toes and bunion procedures

More than 100 procedures have been described for treating hammer toes in conjunction with bunion procedures (Fig. 1). Coding is challenging due to the complexity, methods of treatment, and reimbursement policies for each payor. But the following four steps can help ensure accurate coding and reimbursement for these procedures.

Step 1: Document medical necessity
Surgery for the sole purpose of improving the appearance of the foot is not a covered benefit under most insurance programs. To support medical necessity, the following documentation is required:

• Persistent symptoms at the first metatarsophalangeal (MTP) joint or ulcer development at the site of the bunion, on the sole of the foot, or at the second toe. Table 1 provides examples of International Classification of Diseases, 9th Revision (ICD-9) codes that should support the medical necessity of bunion and hammer toe procedures.
• At least 6 months of conservative therapy involving the use of, for example, shoe modifications, padding or other accommodative devices, corticosteroid injections, nonsteroidal anti-inflammatory drug therapy, physical therapy, or activity modifications.
• Physical exam and radiographic findings such as degenerative changes in the first MTP joint and/or valgus deformity and/or exostosis of the first metatarsal. Requirements may vary by carrier. For example, the Cigna carrier policy requires that degenerative changes between the first and second metatarsals should be greater than 9 degrees. United carrier policy, however, requires documentation of degenerative changes in the first MTP joint and/or valgus deformity greater than 15 degrees and/or significant exostosis of the first metatarsal.

Step 2: Document all conservative and nonsurgical treatments
Initial treatment may include evaluation and an order for orthotics, metatarsal pads, or foot orthoses. You must have a valid Durable Medical Equipment (DME) Regional Carrier license to dispense covered DME items to Medicare patients, use the proper Healthcare Common Procedure Coding System (HCPCS) code, and support the order by medical necessity.

Private insurance carriers will also require that you are credentialed as a supplier. Some carriers, however, have designated suppliers and may require patients to obtain DME items directly from them.

Coverage for foot orthotics varies by carrier. Medicare will not cover an orthopaedic shoe unless it is an integral part of a brace, a therapeutic shoe, or for a diabetic patient. Orthopaedic and therapeutic shoes are coded differently: A codes (such as A5500-A5511) are used for therapeutic shoes for diabetic patients; L codes (such as L3000-L3649) are reported for orthopaedic shoes. Refer to your Centers for Medicare & Medicaid Services local coverage determination for specific carrier guidelines.

Step 3: Use modifiers correctly
Billing for foot surgery often requires billing multiple codes because surgeons can perform forefoot, midfoot, and hindfoot procedures in one session. The use of modifiers is important to correctly identify separate procedures.

Level II (HCPCS/National) “T modifiers” are used to identify surgery performed on specific toes and are found at the back of Appendix A in the Current Procedural Terminology (CPT®) book. They only apply to the phalanges and are not used to identify metatarsal work. For example, to report a left Clayton ostectomy with excision of the second, third, fourth, and fifth metatarsal heads with phalangectomies, use CPT code 28114 without modifiers.

Report hammer toe procedures using T modifiers to indicate the operated toe(s). TA is used for the left hallux, T1 for the second left, T2 for the third left, T3 for the fourth left, T4 for the fifth left, T5 for the right hallux, T6 for the second right, T7 for the third right, T8 for the fourth right, and T9 for the fifth right. Correction of hammer toes on the second, third, fourth, and fifth toes of the right foot would be reported as 28285-T6, 28285-T7, 28285-T8, and 28285-T9.

Some insurance companies may require modifier 59 on the second and all subsequent procedures. Table 2 shows coding for a right Chevron osteotomy, with correction of hammer toes on the second and third right toes and MTP joint capsulotomies on the second and third right toes.

Most bunion procedures include the following procedures, which should not be reported separately: arthrotomy, capsular release and reconstruction synovectomy, synovial biopsy, tendon release or transfer, repair of released tendon, all types of implants and implant fixation, excision of bone or synovial cysts, removal or additional exostoses in the area of the joint, arthroscopy, removal of bursal tissue when performed at the first MTP joint, scar revision, splinting/casting, and resection of first metatarsophalangeal joint. Refer to the AAOS’ coding tool Code-X or the print Global Service Data for Orthopaedic Surgery to avoid unbundling of any orthopaedic procedure.

The use of internal fixation is included in the surgical fee. The use of external fixation may be reported separately if it is deemed medically necessary and reasonable.

Step 4: Report postoperative services accurately
Surgical procedures to correct bunions and/or hammer toes are considered by Medicare and most payors as major procedures with 90-day global periods. The application of the first postoperative splint and/or toe strapping is included during the global period and should not be reported separately. Removal of hardware (such as an exposed K-wire) that is intended to be removed is not reimbursable separately.

Removal of certain fixation may be payable if medically necessary and done surgically, as in the case of implant removal due to infection (CPT code 20680—Removal of implant; deep, ([eg, buried wire, pin, screw, metal band, nail, rod or plate]). If removal is performed within the surgical global period, append modifier 78 (Unplanned return to the operating/procedure room by the same physician following initial procedure for a related procedure during the postoperative period) to the CPT code.

Although following these four steps doesn’t guarantee that your claim will be accepted, your initial investment of time to support medical necessity will be important for your appeal. Always use your coding tools (e.g., CPT, Code-X, ICD-9) as a reference. A carrier’s reimbursement policy may contradict standard coding practices. Denial reasons can be misleading. Start by calling the carrier to find out why the services were denied. Tracking denials by payor will help staff spot denial trends to streamline the appeal process and get you paid more quickly.

Teri A. Gatchel, MBA, is a consultant with KarenZupko & Associates. The information in this article has been reviewed for accuracy by members of the AAOS Coding, Coverage, and Reimbursement Committee. If you have coding questions or would like to see a coding column on a specific topic, e-mail aaoscomm@aaos.org