Answers to your questions on foot and ankle coding

Reporting services for foot and ankle procedures—especially surgery on the toes—is challenging. Payer rules related to modifiers further complicate the claims submission process and increase the challenges faced by the appeals team.

Modifier usage, as well as payers’ acceptance of modifiers 50, 51, 59 and the toe modifiers discussed in this article, is based on CPT rules and Medicare’s Correct Coding Initiatives (CCI) edits. Understanding the rules related to the surgical procedures—in particular, what is and is not separately reportable—is critical to accurate reporting and the use of these modifiers. Unfortunately, payer rules further complicate reporting these services and thus the following examples may have to be ‘modified’ to meet individual payer directives.

Hammertoe repair and bunion procedures
Question: Our foot and ankle surgeon commonly performs hammertoe repairs and bunion procedures together. Based on the AAOS Global Service Data Guide, these procedures are not considered inclusive to each other, yet payers continue to bundle them. Any suggestions?

Answer: You are correct in saying that a hallux valgus correction surgical procedure on the first metatarsal and a bunion procedure on the second toe are separately reportable. The AAOS Global Service Data Guide shows the following procedures as inclusive to CPT code 28296—Correction, hallux valgus (bunion), with or without sesamoidectomy; with metatarsal osteotomy (eg, Mitchell, Chevron, or concentric type procedures):

• arthrotomy (eg, 28022)
• synovial biopsy (eg, 28052)
• tendon release or transfer (eg, 28240)
• synovectomy (eg, 28072)
• capsular release and reconstruction (eg, 28270)
• removal of additional exostoses (eg, 28122, 28124, 28126, 28288)
• internal fixation
• articular shaving
• removal of bursal tissue
• repair of released tendon (eg, 28200, 28208)
• excision of bone or synovial cysts (eg, 28090–28092, 28104, 28108)

A hammertoe repair (CPT code 28285) is not listed as an inclusive procedure to a hallux valgus correction procedure; however, a Medicare CCI edit for CPT code 28296 and CPT code 28285 has been issued. This edit requires that you append the modifier(s) to appropriately override the payer edit (when it exists). Two modifiers—modifier 59 and the “T” or toe modifier (Table 1)—may be appropriate to indicate the procedures as distinct and separate from each other. Some payers may not require any modifier, some may require the modifier 59, some may require the T modifier, and some may require both.

A review of Medicare carrier claims nationwide found payers that require both modifiers and other Medicare carriers that require only one.

For example, the surgeon documents a hallux valgus correction to the first metatarsal of the right foot and a hammertoe repair to the right foot second toe. If both modifiers are required to appropriately document the two procedures, the code combination is reported as follows:

28296*
28285-59, T6

*It is acceptable to append the T5 modifier to CPT code 28296 if necessary, based on payer rules.

This example indicates that the hammertoe surgery is distinct from the bunion procedure and provides the anatomic location of each surgery. Although this appears to be overkill, it might be required based on payers’ claim processing and edit systems.

Hammertoe repair and capsulotomy
Question: Does a hammertoe repair include a capsulotomy?

Answer: To answer this question, the location of the capsulotomy must be identified. A capsulotomy of the interphalangeal joint (CPT code 28272) is included in a hammertoe repair (CPT code 28285) performed on the same toe. A metatarsophalangeal joint capsulotomy for a joint contracture (CPT code 28270) is not inclusive to 28285, because the capsulotomy is performed on a different joint than the hammertoe repair.

For example, the surgeon performs a hammertoe repair on the left second toe and a capsulotomy on the metatarsophalangeal joint on the same toe. The procedure is reported as follows:

28285-T1
28270-59, T1*

*Some payers may not require the T1 modifier because this is a joint space.

Apply the modifiers as appropriate based on the individual payer’s rules and internal denial/rejection experiences.

Pediatric foot deformity/gait abnormality
Question: How do you recommend reporting the following procedures performed by a pediatric orthopaedic surgeon for a child with contractures, foot deformities, and a gait abnormality? The procedures are dictated as “bilateral calcaneal osteotomies, bilateral gastrocnemius recessions, and bilateral posterior tibialis tendon advancements.”

Answer: These procedures are commonly performed by pediatric orthopaedic surgeons. Table 2 shows the CPT code recommendations based on the information provided.

In this scenario, CPT code 27691 is reported on two lines and modifier 50 is appended to only one code on a single line. This is the correct reporting according to CPT rules. Modifier 50 is appended to the second code indicating that the exact procedure was performed on the contralateral side. Using modifier 50 for the second code avoids the contralateral procedure being denied as a duplicate procedure.

Many payers require single line submission. For these payers, close monitoring of reimbursement is critical to ensure that both procedures are paid appropriately. Medicare requires single line claims submission, but when Medicare reimburses the surgeon, the explanation of benefits will always show payment on 2 lines; payment should be 150 percent of the Medicare Fee Schedule.

The online version of this article shows how to report this procedure to Medicare, and how Medicare will reimburse for it.

Final tips

• Foot and ankle coding presents many challenges related to the intricacies and multiple procedures performed on the joints, tendons, and bones. Work closely with the coding and reimbursement staff to ensure documentation is specific to each anatomic location and the individual procedures performed at each site. The following tips may also be helpful:
• Monitor claims closely for bundling issues and denials of services as incidental to each other or denied as duplicate. These types of denials/rejections will assist in correct modifier application.
• Avoid unbundling; use modifiers correctly according to CPT and individual payer rules.
• Monitor reimbursement closely and do not allow payer activities (such as consistently bundling two procedures) to dictate your coding. This could potentially result in lost revenues and inappropriate write-offs.
• Run an adjustment report to ensure all write-offs for denied/bundled services were accurately made.
• Audit surgical cases to maintain compliance and make certain that inappropriate unbundling/bundling is not occurring and to identify any opportunities to optimize coding, documentation, and revenue.
• Attend an AAOS-sponsored coding course to learn the general coding principles related to surgical and office coding.

Do you have a coding question or problem you’d like to see addressed in an upcoming article? Let us know—e-mail aaoscomm@aaos.org

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