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02/27/2010    

CODINGLINE CORNER

Query: Billing Lapidus/Akin


The doctor performed a Lapidus-type bunionectomy (CPT 28297) and an Akin-type osteotomy (CPT 28310) on a patient. CPT 28310 was denied as inclusive to the Lapidus-type procedure. Does anyone have any suggestions on how I should have billed the procedures? Or how I should appeal the denial?


Sarah Avilleira, Office of Peter A. Wishnie, DPM, Piscataway, NJ


Response: The correct billing for a Lapidus-type bunionectomy and an Akin-type osteotomy is:


#1 CPT 28297 (correction, hallux valgus (bunion), with or without sesamoidectomy; Lapidus type procedure); and CPT 28310-59 (osteotomy, shortening, angular or rotational correction; proximal phalanx, first toe). or


#2 CPT 28740 (arthrodesis, midtarsal or tarsometatarsal, single joint); and CPT 28298-59 (correction, hallux valgus (bunion), with or without sesamoidectomy; by phalangeal osteotomy).


Both coding methods are correct. By the way, the value of coding example #2 is higher than #1. The payer was incorrect in denying CPT 28310 as inclusive (unless you did not add a "-59" modifier to the code). I recommend you appeal with submission of a corrected claim with either one of the coding examples listed above.


It should be noted that CPT 28310 is a designated "separate procedure" code. Separate procedure means that in order to be independently reimbursed, the procedure must not be an integral part of a comprehensive procedure being billed. CPT 28310 needs to be distinct, and in coding example #1, it is.


Harry Goldsmith, DPM, Cerritos, CA


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12/17/2014    

CODINGLINE CORNER


Query:  Correct Billing of Treatment of Nail Trauma


 


How would I bill repair of a laceration of the nail bed of the right hallux that I closed with 7 sutures? There was damage to the nail. 


 


Craig Sapenoff, DPM, West Palm Beach, FL


 


Responses: Laceration coding is typically found in the "repair" sections of CPT. However, for a laceration involving the nail bed, if you look in the "integumentary" section of CPT under nail codes, you will find CPT 11760 - repair of nail bed which describes your treatment of nail bed trauma. It would also include the avulsion of the nail if necessary. 


 


Tony Poggio, DPM, Alameda, CA 


 


To add to Dr. Poggio's post, the ICD-9 code, presuming the presenting condition is primarily the laceration, would be ICD-9 893.0 - open wound of toe(s) (includes: toenail); without mention of complication. Of course, there may be additional ICD-9 codes depending on whether there are complications or a contusion, toe (including toenail) (ICD-9 924.3). 


 


Harry Goldsmith, DPM, Cerritos, CA 


 



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12/13/2014    

CODINGLINE CORNER


Query: Can I Defer Meaningful Use Attestation?


 


I successfully attested for meaningful use for Stage 1 for 2011, 2012, and 2013, but feel that my records are and will not be up to snuff in a timely manner for Meaningful Use attestation for Stage 2 for 2014. Is there anything wrong with not doing Stage 2 this year, and waiting to do it in 2015? Will I lose the final stimulus check by doing that? 


 


Steven D Epstein, DPM, Lebanon, PA


 


Response: If you do not attest to Meaningful Use for 2014, two things will happen. 


 


First of all, you will not get your scheduled incentive payment for your fourth year of attesting to Meaningful Use. If you attest in 2015, you will get the fifth and final payment for MU (you simply skip the fourth payment and lose that amount). 


 


The second thing that will happen is that by not attesting to MU in 2014, you will be subject to the MU penalty in 2016 (a 2% reduction in all of your Medicare Part B payments for that year). Attesting in 2015 to MU will avoid the MU payment reduction in 2017 (3% of all Medicare payments). 


 


Jim Christina, DPM, Bethesda, MD


 



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12/11/2014    

CODINGLINE CORNER


Query: Billing for Custom Orthotics 


 


Are we required to bill at time of dispensing the foot orthotics? Or can we bill at the time of casting for foot orthotics? 


 


Michael DeKorte, DPM, Medford, OR


 


Response: All items of DME are or should be billed at time/date of dispensing - NOT time of casting, or evaluation. In fact, if your medical and billing records disagree on date of billing/dispensing, most payers (especially Medicare) will reject and/or audit the claim, then reject the claim. 


 


On post-payment review (with Medicare), if your records do not reflect a billing date as the same date of dispensing, they consider the service invalid, and "ask" (a kind term for what they actually say, and do) for the money back. 


 


Rick Horsman, DPM, Olympia, WA 


 



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12/10/2014    

CODINGLINE CORNER


RE: ABN Question Regarding DME


 


I have received a few denials on therapeutic shoes and inserts for my advance beneficiary notices for not having the proper wording in box E of the ABN. Box E is part of the section beginning "Medicare does not pay for everything, even some care that you or your health care provider have good reason to think you need. We expect Medicare may not pay for the D below." 


 


"D" is the description of the item in question.  "E" is the "Reason Medicare may not pay" box associated with "D". Please help if you know of the correct wording they are looking for in box E. 


 


Trina, Office of Neil Kelley, DPM, Fortuna, CA


 


Response: That is correct. Your section "E" explanation has to be the specific reason you expect it will not be covered, usually referencing the Medicare policy guidelines. It cannot be a general "if Medicare does not pay, then ..." Example: "previous shoes received less than 12 months since the last pair." When in doubt, verify with the DME MAC for your region prior to ordering the shoes. 


 


Rich Papperman, MBA, CHBME, Cape May Court House, NJ 


 



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12/08/2014    

RESPONSES/COMMENTS (CODINGLINE CORNER)



From: Steven Selby Blanken, DPM


 


I would put the KX modifier prior to the RT or LT modifier. Maybe it was just a glitch for that reason? L4360-KX-RT. I was told that most DMEs to Medicare need this first.


 


Steven Selby Blanken, DPM, Silver Spring, MD

12/06/2014    

CODINGLINE CORNER


RE: CAM Walking Boot Denial


 


On June 13, 2014, I dispensed a pneumatic CAM walking boot to a patient diagnosed with Achilles tendinitis as well as a posterior calcaneal spur. I coded the device as L4360-RT-KX and coded ICD-9 726.73 (enthesopathy, calcaneal spur) and ICD-9 726.71 (Achilles tendinitis). The claim was denied by Medicare stating it did not meet medical necessity. No records were requested. While I am aware that there are new codes for walking boots, I do not think this has any bearing on this claim denial. Where am I lacking medical necessity? 


 


Jack Reingold, DPM, Solana Beach, CA


 


Response: I cannot really see anything that you are missing. It would be important to take a look at the Medicare LCD to find out if they have any recent (last 6 months) changes that might apply to the use of the CAM walker. It appears - at least to me - that recently, many Medicare contractors have been subjectively, and without comment, changing the LCDs...sending us ridiculous statements about the lack of medical necessity. I would first take a look at your local carrier LCD, then appeal, resubmitting the claim. 


 


Mike King, DPM, Fall River, MA 


 



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12/03/2014    

CODINGLINE CORNER


Query: Storage: X-Ray Film vs. Digital


 


How long do I have to store my old x-ray films? 


 


Mark C. Baxter DPM, Kingsport TN


 


Response: X-rays are the same as any other part of a patient's chart and must be kept the same length of time that the rest of a chart should be maintained. 


 


Most experts recommend that charts be held for (7) years. X-rays (and charts) for minors should be held for a variable length which is calculated as until the child reaches the age of majority (usually 18) plus the statue of limitations for malpractice in your state.  Click here for state by state requirements.


 


Barry Block, DPM, JD, Forest Hills, NY 


 


[Dr. Block will be a featured speaker at the Codingline-NYSPMA "Foot & Ankle Coding" Seminar, January 22, New York 


 



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12/03/2014    

RESPONSES/COMMENTS (CODINGLINE CORNER)



From: Brian Kashan, DPM


 


This topic hits a nerve with me, yet affects all of us on a daily basis. We are forced to accept the standards, rules, and policies stuffed down our throats every day. We can’t do this. We have to do that. We have to use this form for this. No form for that. This requires authorization. We can’t hold the member responsible. We can do this in 61 days, but not in 60. This is no guarantee of payment.  On and on for eternity.


 



Now, we get a chance to have the tables turned, and we can tell a patient, “ your insurance company is the one who dictates when we charge you.” After 10 days, your visits will be...



Editor's note: Dr. Kashan's extended-length letter can be read here.



12/02/2014    

RESPONSES/COMMENTS (CODINGLINE CORNER)



From: James W. Clark, DPM


 


I prefer to be reimbursed for my knowledge and expertise, particularly when it involves surgical patients. Have you ever seen what a general surgeon does with an ingrown nail? We podiatrists are SPECIALISTS when it comes to nail surgery. Try doing both borders on one nail; you will only get reimbursed for one border. Have you had a root canal done lately? What did that cost? When I began in private practice, the fee for a dental root canal and nail matrixectomy were the same. Compare those fees today - you'll be shocked!


 


In my area, general surgeons continue to perform cold steel matrixectomies under general anesthesic at our surgery center. We routinely perform these procedures in our office and save the insurance companies untold sums of money. Often, nail surgery patients fail to take their prescribed antiobiotics and follow soaking instructions, resulting in post-operative complications. So, do you want to see these patients for free?


 


A 10-day follow-up on matrixectomies is the accepted policy. After 10 days, it should be fee for service. Don't devalue your medical services. The insurance companies have already done that for us. Remember, we are no longer DOCTORS - we are now "Providers", so say the insurance companies.


 


James W. Clark, DPM, Salinas, CA

12/01/2014    

RESPONSES/COMMENTS (CODINGLINE CORNER)



From: Cynthia Ferrelli, DPM


 


I once discussed this question with a colleague of mine who sat on the NYS Board. It was the Board’s view that these post-operative appointments were really non-billable, even after the global period, since there usually is not much to report to ascertain a CPT 99212. Ever since that discussion, I have not charged for such visits. Usually, I will see the patient twice after a matrixectomy procedure, and we just give them a window of time to show up at the office, i.e., 1-3 PM, or whatever fits into their schedule.


 


The front desk tells them it's just a quick check and that when a room becomes available, I will just take a quick peek and make sure that everything is okay. We tell the patient ahead of time that unless there is some kind of problem, there will not be a co-pay. This way, we don't utilize a slot in the schedule book. This has worked very well for many years.


 


Cynthia Ferrelli, DPM, NMD, Buffalo, NY

11/29/2014    

CODINGLINE CORNER


Query: Co-Pay for F/U Avulsion/Matrixectomy


 


What is the rule, if any, on collecting co-pays for follow-up visits on an avulsion/matrixectomy? I know the global period for a matrixectomy is 10 days and for an avulsion is 0 days. So, if I am seeing follow-up visits at 14 days for both avulsion and matrixectomy, am I billing for an office visit and therefore collecting copays since I am out of the global period, or am I not billing and collecting anything since it is a follow-up for a procedure? 


 


Charles Baik, DPM, Tustin, CA


 


Response: First off, just in case there is any confusion, the avulsion would be part of the matrixectomy. The matrixectomy has a global period of ten days. After ten days, you can see the patient as medically necessary and charge a co-pay, per insurance plan. 


 


Tony Poggio, DPM, Alameda, CA


 



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11/26/2014    

CODINGLINE CORNER


Query: CPT 64450 Denial - Not Medically Necessary


 


Over the last few months, Medicare has denied every CPT 64450 claim we have submitted using diagnosis code, ICD-9 355.8 (mononeuritis of lower limb, unspecified). According to the LCD for CPT 64450, ICD-9 355.8 is an acceptable diagnosis code. I am aware of the limit of three billings of CPT 64450 in a six-month time frame, but none of these denials have exceeded this limit. Am I missing something? Is there a new CPT code to be used with ICD-9 355.8 just as CPT 64455 is dedicated to ICD-9 355.6 (Morton's neuroma)?


 


Gary A. Lieber, DPM, Delray Beach, FL


 


Response: The key here is that the LCD appears clear. This happens all over the country, and if your carrier has a written policy on the use of CPT 64450 and you are following it, the claim should be paid. Appeal with copies of the notes and the LCD, and see what they say. The same problem is happening now in New England with NGS. Use the LCD as your leverage and make sure your notes are complete as to the medical necessity, of course, without tinkering with already made notes. 


 


Mike King, DPM, Fall River, MA


 



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11/22/2014    

CODINGLINE CORNER


Query: Which code: CPT 28126 or CPT 28160?


 


Which code would be most appropriate to bill when the prominent head or base of the phalanx is partially removed due to a painful overlying corn, CPT 28126 or CPT 28160? 


 


Lynn Stafford, DPM, Fort Wayne, IN


 


Response: Let's look at the two CPT codes you asked about 


 


1) CPT 28126 - resection, partial or complete, phalangeal base, each toe 


2) CPT 28160 - hemiphalangectomy or interphalangeal joint excision, toe, proximal end of phalanx, each 


 


So, if you are removing an interphalangeal joint, meaning the base of the middle phalanx and the head of the proximal phalanx, then it is CPT 28160. 


 


If correcting the hammertoe, then it would be CPT 28285 -correction, hammertoe (e.g., interphalangeal fusion, partial or total phalangectomy). This procedure allows for removal of part of the phalanx, i.e., the head of the proximal phalanx. If just doing the phalangeal base, then use CPT 28126. 


 


David J. Freedman, DPM, CPC, Silver Spring, MD 


 



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11/19/2014    

CODINGLINE CORNER


Query: Use of Multiple Skin Substitutes


 


If you apply Apligraf to a wound 5 times (separate surgical sessions over time), the maximum allowed applications by my Medicare contractor, but fail to get closure, would you be allowed to switch to a different skin substitute product (e.g., Dermagraft) to achieve closure? If so, when would it be acceptable (reimbursable)? 


 


Louis Cappa, DPM, New Windsor, NY


 


Response: I think this depends on your LCD. Make sure your documentation supports the need and explains why you think switching to a different product will make a difference. I would try to pre-certify or contact Medicare before moving forward. 


 


Jeffrey Lehrman, DPM, Springfield, PA 


 



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11/15/2014    

CODINGLINE CORNER


Query: AFO Replacement After 2 Years


 


I am presently treating a patient who was fitted with an AFO after a CVA around 2 years ago. He was fitted in a hospital after the stroke. The brace is still in a good shape, but the patient's leg is more swollen now and as a result, he developed pressure blister in a few places. This makes him uncomfortable. I tried using padding but it doesn't help. In my opinion, this patient needs to be re-cast for a new device. Would Medicare DME pay for a new brace if it has been less than 5 years since the old one was fabricated? Do I need to send medical records in order to prove my point? 


 


Boris Raginsky, DPM, East Brunswick, NJ


 


Response: While, yes, it is true that Medicare says the brace should have a lifetime for a period of 5 years, if there is medical necessity (you mentioned that the AFO no longer conforms to the patient's leg anatomy) and if the device cannot be adjusted, prescribe a new one. Have the patient sign an advance beneficiary notice (ABN) because of the 5-year rule. As long as you document why a new device is medically necessary, you should be reimbursed for dispensing a new AFO. 


 


David J. Freedman, DPM, CPC, Silver Spring, MD 


 



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11/13/2014    

RESPONSES/COMMENTS (CODINGLINE CORNER)



From: Andrew Carver, DPM


 


This argument about "night splints" seems to be quite a moot point, as part of the methodology of improving or curing plantar fasciitis pain. Every time I have surgically touched the plantar fascia, I realized that that tissue cannot be "stretched" longitudinally. I believe the 'night splint' was the invention of the foot and ankle orthopedic community because they did not want to admit that orthoses were actually the best treatment. Podiatry developed the orthotic. 


 


In my opinion, a night splint only affords 'compression' to the area at night - therefore disallowing the edema to the plantar heel extra-cellular space during non-weight-bearing. Patients get up and walk on the heel in the morning and most often the pain greatly improves. The swelling that occurs because of this at night causes ALL the 'morning heel pain.' It just so happens that the night splint disallows this swelling; therefore patients and practitioners surmise that the night splint is stretching the fascia. I do not think so.


 


I put my fasciitis patients in a 'Copper foot/heel sleeve' at night and get the same pain improvement that the night splint affords. I just do not believe that there is any way to stretch the plantar fascia  (Well, maybe with ECSW).


 


Andrew Carver, DPM, Washington, DC, andrewlcarver@gmail.com

11/12/2014    

RESPONSES/COMMENTS (CODINGLINE CORNER)



From: Ken Meisler, DPM


 


Dr. Ribotsky makes it sound like every patient who has bilateral plantar fascitis should use two night splints. I have treated thousands of patients with plantar fasciitis, many bilateral, and almost every patient who is able to sleep with a night splint finds it very helpful. I always start with one night splint and when they come in for a follow-up in a few weeks, I offer a second one. I have found that greater than 90% of the patients do NOT want to use a second night splint, even if the first one is helping significantly.  


 


I tell patients with bilateral plantar fasciitis to use the splint on the leg that has the more severe plantar fasciitis and, then when that foot is the same as the other foot, to alternate legs each night. Patients seem to rather have their fasciitis get better a little more slowly than sleep with two night splints.  


 


90% of the patients I treat for plantar fasciitis are NOT seniors. Perhaps Dr. Ribotsky has an older population and they sleep more soundly, or maybe people in Florida just sleep better than New Yorkers, but I always ask knowing what the patient will say and still get a laugh at the look on their faces at the thought of sleeping with two night splints.


 


Ken Meisler, DPM, NY, NY, kenmeisler@gmail.com

11/12/2014    

CODINGLINE CORNER


Query: Tendon Repair with Use of GraftJacket


 


Please advise as to the most appropriate code(s) for repair of a partially torn posterior tibial tendon with use of GraftJacket. 


 


Stuart Honick, DPM, Mays Landing, NJ


 


Response: The use of GraftJacket does not influence the tendon repair code you choose (in this case, CPT 28200 - repair, tendon, flexor, foot; primary or secondary, without free graft, each tendon). There is no specific code for the application of GraftJacket in tendon repair. Typically, unless you get authorization for additional allowance pre-op, you might very well find that there is no extra allowance for its use in reinforcing a tendon repair. 


 


Some surgeons have added a "-22" increased procedural services modifier to the repair code. Others have billed the unlisted foot/toe code, CPT 28899. I can't tell you if they have been successful. 


 


Tony Poggio, DPM, Alameda, CA 


 



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11/11/2014    

RESPONSES/COMMENTS (CODINGLINE CORNER)



From: Bret Ribotsky, DPM


 


I disagree with my friend Dr. Kesselman on his response about having a patient split the wearing of a night splint between legs. Really? Have we all just bowed down to the "insurance gods" and given in? I am sure if Paul were to come down with plantar fasciitis, he would sleep with two splints.  


 


Maybe the next time I get my eyes checked and they find only a problem with one eye, the doctor will prescribe a monocle. Maybe if I have a patient with a wound on both legs, I could share the VAC one day left, one day right. Please, we must never lose sight of the fact that we must do what is best for the patient. If the insurance company only wants to pay for one night splint, I leave it up to the patient to complain to the insurance gods. I tell the patient that this is the cost of the second splint and have them get it. The motivated patient wants to get better quickly, and the physician who treats patients to a speedy recovery will have a significant advantage today and in the future.


 


Bret Ribotsky, DPM, Boca Raton, FL, Ribotsky@gmail.com

11/08/2014    

CODINGLINE CORNER


Query: Bilateral Night Splints


 


When a patient presents with bilateral plantar fasciitis, is it acceptable to dispense and bill for two night splints (L4396)? 


 


Charles Perry, DPM, Cambridge, OH


 


Response: While the policy would allow for dispensing bilateral night splints, I have in the past only dispensed a single night splint to any given patient, telling them to wear it on the right side on even days, the left side on odd days, or whatever means of reminder works for them. I do not suggest dispensing bilateral night splints. 


 


You need to separate medical necessity and reimbursement policy from practicality. Do you really expect the patient to remove the night splints (both of them) at 2 AM if they need to go to the bathroom and then re-apply them? If kept on, one of these splints is difficult enough to sleep with and navigate; can you imagine two? 


 


Paul Kesselman, DPM, Woodside, NY 


 



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11/05/2014    

CODINGLINE CORNER


Query:  Ulcer & Ostectomy Coding


 


What code would I use for excision of ulcer with ostectomy (1st metatarsal head)? 


 


Diane M. Phalen, DPM, San Marcos, TX


 


Response: It depends on the specific circumstances. A partial exostectomy would be coded as CPT 28288, CPT 28122, CPT 28104, or, if the entire metatarsal head was excised, CPT 28111. Where was the ulcer? If it was overlying the incision area (where, for example, a simple ellipse would remove all the non-viable tissue), then typically that procedure would be a component of the more comprehensive bone resection. 


 


Tony Poggio, DPM, Alameda, CA 


 



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11/03/2014    

RESPONSES/COMMENTS (CODINGLINE CORNER) - PART 1B



From: Ivar E. Roth, DPM, MPH 


 


After reading what CMS states concerning documentation,  I was wondering if the following scenerio would qualify for neuroma injections with alcohol for sclerosing the nerve? “Ultrasound guidance was used to accurately inject into the nerve without injecting the vasculature or muscle, the neuroma was not injected. The sclerosing agent was injected just proximal to the neuroma, into the 2mm nerve.” Other issues are: how would you inject .5cc of anything into a 2mm nerve?  


 


Lastly, this podiatrist used this code seven times in a row over the course of the treatment for the injection, and was paid $250 each time for the use of the ultrasound. Does this make sense? I think that one would figure out after the first time where to inject for the future injections, and not need to do this SEVEN times. Am I wrong?


 


Ivar E. Roth, DPM, MPH, Newport Beach, CA, ifabs@earthlink.net 

11/03/2014    

RESPONSES/COMMENTS (CODINGLINE CORNER) - PART 1A



From: Elliot Udell, DPM


 


Ms. Merkow states that one must document the following prior to giving an ultrasound-guided injection: "initial attempt to inject failed; the patient's obesity impairs your ability to inject accurately; etc."


 


The literature is split on whether the use of ultrasound guidance in giving a musculoskeletal injection yields better results. If a doctor subscribes, however, to the studies that show that ultrasound guidance does improve clinical outcomes, he or she should not have to show "failed" attempts, or a "patient's obesity", in order to be reimbursed for the procedures.


 


Elliot Udell, DPM, Hicksville, NY, Elliotu@aol.com

11/01/2014    

CODINGLINE CORNER


Query: Documentation Guidelines: Ultrasound-Guided Injections


 


After unsuccessfully searching the CMS website for this information, we are looking for assistance. Can someone guide us to a resource that will give us the documentation requirements for ultrasound-guided injections? Do we need to develop a separate form for this procedure? We understand that CMS will be heavily auditing these procedures in the future and want to be correctly documenting. 


 


David Sandberg, DPM, Knoxville, TN


 


Response: You may be frustrated by CMS because they are updating LCDs at this time and many are not listed. I can't cite a resource for that reason, however permanent copies of the recorded images must be maintained in the patient record when ultrasound is used to guide a procedure. Images can be stored as printed or digital images. The reported description can be dictated as a separate procedure or as part of the procedure for which the guidance is used, but it MUST be included. Your documentation must indicate medical necessity (i.e., initial attempt to inject failed; the patient's obesity impairs your ability to inject accurately; etc.). Obviously, you must select a diagnostic code that determines medical necessity. 


 


All of the above must be included in the patient's record AND must be readily submitted to the payer upon request. Because we include medical necessity in our records all of the time for routine foot care, motor vehicle, and Workers' Comp claims, this isn't as bad or ominous as it sounds. 


 


Lisa Merkow, CPC, Largo, FL 


 



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10/29/2014    

CODINGLINE CORNER


Query: Repair of Non-union Toe


 


I cannot find a code for a surgery performed on a patient. The surgery was to repair a non-union proximal interphalangeal joint. There is a code for a non-union repair of tarsal bones (CPT 28320), but not of the interphalangeal joint. What code do you suggest? 


 


Walter Warren, DPM, Seymour, IN


 


Response: The closest thing I can relate for surgery to repair a non-union proximal interphalangeal joint is CPT 28525 - open treatment of fracture, phalanx or phalanges, other than great toe, with or without internal or external fixation, each. An interphalangeal joint involves two phalanges; this code allows for the repair of phalanges in my opinion. 


 


David J. Freedman, DPM, CPC, Silver Spring, MD 


 



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