Orthopedic Coding Alert

Dont Get out of Joint When Coding Lisfranc Fracture-Dislocations

Published on Mon Jul 01, 2002

Fracture-dislocations of the tarsometatarsal joint nicknamed Lisfranc"" after a field surgeon in the Napoleonic army often involve repair of several dislocated tarsometatarsal (TMT) joints as well as proximal metatarsal fractures" resulting in the need to report multiple procedures. Coding each joint repair procedure separately with the toe modifiers appended can prevent improper rebundling and increase reimbursement for these commonly performed surgeries.

Lisfranc injuries occur when force directed at the ball of the foot causes joint displacement and often fractures. Repair of an associated proximal metatarsal fracture should not be billed separately using the tarsal fracture repair codes (28450-28485) because these services are included in the dislocation treatment codes.

Tarsometatarsal joint dislocations should be coded using the 28600-28615 range. Billing multiple units of these codes to denote the toes repaired however creates a challenge.

Coding Multiple Joints Can Be Tricky

"Reimbursement occasionally becomes problematic when multiple tarsometatarsal joints are addressed at the same operative session " according to Heidi Stout CPC CCS-P coding and reimbursement manager at University Orthopaedic Associates in New Brunswick N.J. Carriers tend to bundle the codes and CPT's verbiage contributes to the confusion "because while the code descriptors imply that each code is for a single joint dislocation the descriptors do not include the language 'each ' " Stout explains.

For instance 28615 (Open treatment of tarsometatarsal joint dislocation with or without internal or external fixation) does not refer to "dislocation(s) " as is often the case when CPT means to imply that a code applies to one or more dislocations. However the absence of the word "each " which is included in the descriptions for toe fracture codes 28450-28485 leaves the joint repair codes open to carrier interpretation.

"Reporting 28615 as a multiple elicits a variety of responses from payers " Stout says. "Some readily accept and reimburse for this code as a multiple while others will pay on only the first line item. Bundling also occurs when a combination of open (28615) and percutaneous (28606 Percutaneous skeletal fixation of tarsometatarsal joint dislocation with manipulation) treatment codes are submitted. Appending modifier -59 (Distinct procedural service) to 28606 can prevent this from occurring."

For example suppose the operative report reads "Rt foot Lisfranc dislocation with instability of all five TMT joints. Procedure: Open treatment of second TMT joint. Percutaneous fixation of 1 3 4 5 TMT joints. Stress x-rays of right foot."

The practice should submit the claim with the codes listed as follows:

28615-T1 (Left foot second digit)

28606-TA (Left foot great toe)

28606-T3 (Left foot fourth digit)

28606-T4 (Left foot fifth digit)

28606-T5 (Right foot great toe)

76006 (Radiologic examination stress view[s] any joint stress applied by a physician [includes comparison views]).

If your payer bundles your claim for multiple tarsometatarsal dislocation repairs and you therefore receive payment for only one dislocation treatment appeal the denial by writing a letter to the insurer with a copy of your operative report. Explain to the medical director that the orthopedist performed separate procedures for each dislocated joint resulting in more work and time than one dislocation would have required.

Because many carriers do not publish local medical review policies (LMRPs) for these dislocation treatment codes it's a good idea to write to your carrier and ask for a copy of its billing guidelines for these services. That way when the time comes to bill for Lisfranc repairs you will know exactly what your carrier requires.