Orthopedic Coding Alert

Question: After a level-three evaluation and management (E/M) service for an established patient, our orthopedist performed a partial phalangeal base resection on a patient’s right great toe; and a complete resection on a patient’s right second digit. How should I code this encounter?

Florida Subscriber

Answer: In order ensure the claim has the greatest possibility of acceptance, you’ll probably need to employ some seldom-used modifiers to separate the phalangeal base resections.

On the claim, you should:

• Report 28126 (Resection, partial or complete, phalangeal base, each toe) for the great toe resection.
• Append modifier T5 (Right foot, great toe) to 21826 to indicate the anatomy of the injury and treatment.
• Report 21826 again for the second digit resection.
• Append modifier T6 (Right foot, great toe) to 21826 to indicate the anatomy of the injury and treatment.
• Report 99213 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: An expanded problem focused history; An expanded problem focused examination; Medical decision making of low complexity …) for the E/M service.
• Append modifier 57 (Decision for surgery) to 99213 to show that the provider performed a separate E/M prior to the phalangeal base resections.

Why use T mods? It might be easier to just report 21826 x 2 and forget about the toe modifiers. This isn’t advisable, however, particularly on this claim. If you report 21826 twice without indicating that the provider performed it on two separate toes, the payer might have issue with your claim.