Orthopedic Coding Alert

Suppose your surgeon performs an open reduction/internal fixation of a left-foot Lisfranc fracture dislocation. The surgeon documents reducing the first through fifth metatarsals, but incision documentation doesn't indicate open or percutaneous repair for the third, fourth and fifth metatarsals.

Although the surgeon most likely performed a percutaneous procedure, you can't assume. The documentation is deficient, and the surgeon needs to create an addendum to the op report. The clarification will also allow you to choose the most accurate code.

Suppose that based on the documentation, you have to choose between open treatment code 28615 (Open treatment of tarsometatarsal joint dislocation, includes internal fixation, when performed) and percutaneous code 28606 (Percutaneous skeletal fixation of tarsometatarsal joint dislocation, with manipulation).

According to the 2008 fee schedule, 28615 has 19.85 transitioned facility relative value units (RVUs) and 28606 has only 10.19 RVUs. Translation: Code 28615 pays nearly twice as much as 28606. That difference adds up with this five-metatarsal procedure.

For an open procedure, you would report five units of 28615-LT (Left side) on separate line items, with modifier 59 (Distinct procedural service) appended to the second through fifth line items.

If the surgeon fixed the first and second joints as open procedures, but repaired the third, fourth and fifth joints percutaneously, you should report two units of 28615 and three units of 28606:
- 28615-LT
- 28615-59-LT
- 28606-59-LT
- 28606-59-LT
- 28606-59-LT.-

Because the Correct Coding Initiative bundles 28606 into 28615, you should append modifier 59 to the line items representing the percutaneous procedures.

Reality: If you report 28606 when you should report 28615, you-re shortchanging yourself significantly. If you report 28615 when you should report 28606, you-re brining in overpayments that you-ll have to repay. And if you don't have the doctor clarify his documentation, an auditor will allow payment only for the lower-reimbursed code.