Orthopedic Coding Alert

Question: I need help with billing multiple units of 28485-LT. We reported the following CPT^® codes and ICD-10-CM codes:

CPT^®: 28485-LT, 28485-XS-76-LT, 28485-XS-76-LT

ICD-10-CM: S92.322A, S92.332A, S92.342A

The payer reimbursed the first two CPT^® codes but denied the third, citing the code as duplicate. How should we correct the claim?

Oregon Subscriber

Answer: Billing multiple units of 28485 (Open treatment of metatarsal fracture, includes internal fixation, when performed, each) can be a tricky endeavor, and Revenue Cycle Insider has gathered three tips to help you correct your claim:

Tip 1 – Eliminate laterality: According to the Medicare Physician Fee Schedule, 28485 features a bilateral indicator of “0,” which means that you cannot use laterality modifiers such as LT (Left side), RT (Right side), or 50 (Bilateral procedure) with the code. Some payers may prefer laterality indicators, like appending LT to each instance of 28485 as in your claim; however, it is incorrect coding according to the Centers for Medicare & Medicaid Services (CMS) guidelines.

Tip 2 – Modify your modifier use: Even though the procedure was performed repeatedly, the surgeon performed the procedure on different metatarsals. CPT^® code 28485 is repeated three times in your claim, but each instance is a different procedure. Therefore, modifier 76 (Repeat procedure or service by same physician or other qualified health care professional) is incorrect in this situation.

Instead, you’ll need to show that each procedure was distinct and needed for the encounter. You could delete the instances of 76 and just use XS (Separate structure, a service that is distinct because it was performed on a separate organ/structure).

Tip 3 – Check with the payer: Of course, you can always contact the payer to confirm how it would prefer the case to be reported. The payer may have specific rules regarding reporting multiple units of the same procedure performed on different body structures.

You may also need to appeal the denial. Even though the third procedure is cited as a duplicate procedure, the attached diagnosis code is different because the physician performed the procedure on a different metatarsal (emphasis added):

• 28485 à S92.322A (Displaced fracture of second metatarsal bone, left foot, initial encounter for closed fracture)
• 28485-XS à S92.332A (Displaced fracture of third metatarsal bone, left foot, initial encounter for closed fracture)
• 28485-XS à S92.342A (Displaced fracture of fourth metatarsal bone, left foot, initial encounter for closed fracture)

Therefore, appealing the decision might be necessary in this situation.

Mike Shaughnessy, BA, CPC, Production Editor, AAPC