Podiatry Coding & Billing Alert

Hint: Don't assume all tenotomies are automatically included in hammertoe corrections.

Hammertoe surgery -- 28285 (Correction, hammertoe [e.g., interphalangeal fusion, partial or total phalangectomy]) -- is one of the most often-performed procedures by podiatrists. Our experts answer some of your biggest hammertoe coding questions, from K-wire removal to implant insertions.

Can I bill for the removal of a K-wire?

No, you may not bill the removal of a K-wire separately. It is bundled into the procedure. Using 10120 (Incision and removal of foreign body, subcutaneous tissues; simple) would also be inappropriate. If the pin is outside the skin, you can't bill for it. However, if it needs to be removed because it has been cut and buried beneath the skin, try 20680 (Removal of implant; deep [e.g., buried wire, pin, screw, metal band, nail, rod or plate) and add modifier 78 (Unplanned return to the operating/procedure room by the same physician following initial procedure for a related procedure during the postoperative period), which tells the insurance company it was necessary to do a second procedure on the patient.

Background: Hammertoes are of two kinds -- both of which are billable using 28285, says Walter J. Pedowitz, MD, CPT Advisory Committee Member for the American Orthopaedic Foot and Ankle Society. Flexible hammertoes can be diagnosed and treated while still in the developmental stage, so podiatrists consider it less serious. Not to mention, flexible hammertoes are still moveable at the joint. On the other hand, rigid hammertoes are more serious, and can occur in patients with severe arthritis. In this type, the tendons have become tight and the joint misaligned and immobile. The only possible way to treat patients with rigid hammertoes is through surgery. "The cartilage on the base of the middle phalanx is roughened up to promote arthrofibrosis, and the complex is then straightened and fixed with a K-wire," explains Pedowitz.

Is a tenotomy included in the hammertoe procedure? I've heard both yes and no.

Yes, the tenotomy is included, say experts, and it should not be billed for separately. However, if you look closely at the current National Correct Coding Initiative edits, only 28234 (Tenotomy, open, extensor, foot or toe, each tendon) is listed as bundled into the procedure, not 28232 (Tenotomy, open, tendon flexor; toe, single tendon [separate procedure]). The flexor tenotomy procedure may be billed separately if a separate incision is used.

To bill for this, you would append modifier 59 (Distinct procedural service) to the hammertoe correction code, 28285, with the appropriate documentation. Not all carriers will reimburse for this procedure, so check with your carrier.

What exactly is included in a hammertoe procedure?

Incision of bone (the arthroplasty), tenotomy, tendon transfer, capsulotomy, anyfusion or fixation, fixation with K-wire, all correction of soft tissue, incision, excision, and insertion of implants.

Can I use the hammertoe correction code, 28285, for an arthroplasty with an MTP joint implant?

You should use unlisted-procedure code 28899 (Unlisted procedure, foot or toes) for this procedure because, while similar, the problem is a not a hammertoe -- and if you were to be audited, billing it as such would be fraud because there is no mention of the hammertoe condition in the operative report.

You should not attach modifier 22 (Increased procedural services) to an unlistedprocedure code. In addition to the T modifier to indicate which toes were operated on, you may need to use 78, 79 (Unrelated procedure or service by the same physician during the postoperative period), 58 (Staged or related procedure or service by the same physician during the postoperative period), 50 (Bilateral procedure), or other modifiers under certain circumstances.

Pitfall: Another common misconception about 28285 is that you can report this code for a tendon transfer only. You may not report this code unless you perform a full hammertoe procedure.

My payer doesn't recognize toe modifiers. What can I use instead?

You might need modifiers to help differentiate work on different areas of the feet or toes, says Denise Paige, CPC, coding and billing manager at Beach Orthopedic Associates in Long Beach, Calif., and the president of the AAPC's Long Beach Chapter. However, it is not unusual to have a carrier disallow the use of the toe modifiers, which run sequentially from TA (Left foot, great toe) and T1 (Left foot, second digit) to T9 (Right foot, fifth digit). To distinguish between toes operated on, try using modifier 59. You can also use modifier 59 in conjunction with the toe modifiers; e.g., 28899-59-T3.

Since there is really no treatment for a broken toe, you could bill the office visit 9921x-24 (Unrelated evaluation and management service by the same physician during a post-operative period) and include the ICD-9 code for a fractured toe, 826.0 (Fracture of one or more phalanges of foot, closed).

Consider reporting hammertoe code 28285 for the correction of claw toe or mallet toe.