Wiki 28010 multiple toes (Medicare patient)

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Jamie Dezenzo

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Hi all,
I had a patient 28010x10 (all toes addressed)…Did originally bill 28010 w/ T modifiers and rec'd denial. Checked w/ office and then billed 28010 10 units and no modifier.

Still rec'd denial “Payment adjusted because the payer deems the information submitted does not support this many/frequency services.”
Op note reads:
Attention was directed to the plantar surface of the toes. The toes all had a flexion contracture and the patient had a very flexible foot structure. A percutaneous 1-cm incision was made at the plantar surface of all 10 toes and a flexor tenotomy was performed by incising the FDL and FHL tendons at each of the incisions. This decreased the flexor contracture of the toes. The incisions were then irrigated and surtured w/ a single 4-0 Prolene suture in a horizontal mattress suture technique under each toe.


Medicare indicated to review LMRP but can't find any info….any insight?

ASC in Indiana….Thanks!
 
per 2008 procedure desk reference

28010-28011
This procedure is performed to correct mallet or hammer toe. The physician makes a small incision at the crease of the toe where the tendon is restricted. The tendon is released from the bone and the toe is straightened. The incision is sutured and dressing applied

REPORT 28011 IF MORE THAN ONE TOE IS BEING STRAIGHTENED.
 
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This should be 'per' toe as indicated in the description with multiple tendons being released in that given toe.

T1 Left foot, second digit
T2 Left foot, third digit
T3 Left foot, fourth digit
T4 Left foot, fifth digit
T5 Right foot, great toe
T6 Right foot, second digit
T7 Right foot, third digit
T8 Right foot, fourth digit
T9 Right foot, fifth digit
TA Left foot, great toe


per your op note "a flexor tenotomy was performed by incising the FDL and FHL tendons at each of the incisions"
 
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Lay Description

This procedure is performed to correct mallet or hammer toe. The physician makes a small incision at the crease of the toe where the tendon is restricted. The tendon is released from the bone and the toe is straightened. The incision is sutured and dressing applied. Report 28011 if more than one toe is being straightened.
 
multiple toes

I agree with 20811 for multiple toes. One time only. The description is for "multiple tendons".

According to 3M and encoder pro, if more than one tendon is accessed and cut, use 20811.
 
In our area of the country, Medicare reimburses $107.73 for 28010 and $760.61 for 28011. Considering the lay description of 28011 and the heft of the reimbursement for 28011, I'd say all of the piggies are covered.
 
martn said:
I say 28011 x2 for bilateral?
Click to expand...

I would say no, the description of the procedure is for multiple tendons, so my thought process would be it doesnt matter if its 1 or all 10. BUT..I've put a message out on the ortho list serve to see if anyone has anything in writing on this...I will follow up when I hear back.
 
Here is one response:




This is from the PPRVU
bilat surg=0

0=150% payment adjustment for bilateral procedures does not apply. If procedure is reported with modifier -50 or with modifiers RT and LT, base the payment for the two sides on the lower of: (a) the total actual charge for both sides or (b) 100% of the fee schedule amount for a single code. Example: The fee schedule amount for code XXXXX is $125. The physician reports code XXXXX-LT with an actual charge of $100 and XXXXX-RT with an actual charge of $100. Payment should be based on the fee schedule amount ($125) since it is lower than the total actual charges for the left and right sides ($200).

The bilateral adjustment is inappropriate for codes in this category (a) because of physiology or anatomy, or (b) because the code description specifically states that it is a unilateral procedure and there is an existing code for the bilateral procedure.

(credit to Laura P)
 
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here is another response:

I have an old MEDICARE CORRECT CODING GUIDE 2005 by Ingenix (which I don't really use any more)but it states in the code 28011 that the 50 modifier rule does NOT apply - meaning that you should not use that modifier...

(credit to Anne H)
 
I agree Mary. 28011 has a bilateral payment indicator of Zero ( 0) on the Medicare fee schedule.

0=Bilateral Surgery (50) 0 = 150% payment adjustment for bilateral procedures does not apply. Do not use -50 modifier.
 
thanks Rebecca..You must have seen the post elsewhere too!!...lol :)

Here is another:

Code 28011 has a zero indicator regarding bilateral. Here is what what the Medicare Physician Fee Schedule Database says.

MEDICARE PHYSICIAN FEE SCHEDULE DATA BASE (MPFSDB)

Indicators listed in this data base are assigned by the U.S. Government, Department of Health and Human Services, Centers for Medicare and Medicaid Services. Changes may be made on a quarterly basis.
Indicators show if a specific modifier can be used with a CPT code and how the modifier affects payment.

BILATERAL SURGERY (Modifier 50)

0 150% payment adjustment for bilateral procedures does not apply.
If procedure is
reported with modifier 50 or with modifiers RT and LT, base payment for the two sides
on the lower of the total charge for both sides or 100% of the fee schedule amount for a
single code.The bilateral adjustment is inappropriate for codes in this category
because of physiology or anatomy or because the code description states that it is a
unilateral procedure and there is no existing code for a bilateral procedure.
1 150% payment adjustment for bilateral procedure applies. If
code is billed with a
bilateral modifier (50) or is reported twice on the same day by any other means (eg with
the RT and LT modifiers or with 2 in the units field) base payment for these procedures
when reported as bilateral procedures on the lower of the total actual charge for both
sides or 150% of the fee schedule for a single code.If code is reported as a bilateral
procedure and is reported with other procedure codes on the same day, apply the
bilateral adjustment before applying any applicable multiple surgery rules.
2 150% payment adjustment for bilateral procedures does not apply.
RVUs are based
on the procedure being performed as a bilateral procedure. If procedure is reported
with modifier 50 or is reported twice on the same day by any other means (eg with the
RT and LT modifiers or with 2 in the units field) base payment for both sides on the
lower of the total actual charge for both sides or 100% of the fee schedule for a single
code.
3 The usual payment adjustment for bilateral procedures does not
apply. If procedure is
reported with modifier 50 or is reported for both sides on the same day by any other
means (eg with the RT and LT modifiers or with 2 in the units
field) base payment for
each side or organ or site of a paired organ on the lower of the total actual charge for
each side or 100% of the fee schedule for each side.If procedure is reported as a
bilateral procedure and with other procedure codes on the same day, determine the fee
schedule amount for a bilateral procedure before applying any applicable multiple
procedures rules. Services in this category are generally radiology procedures or other
diagnostic tests, which are not subject to the special payment rules for other bilateral
procedures.
9 Concept does not apply.

(credit to Faye P)
 
While I agree with what you all have said and references posted, shouldn't you be able to bill -RT and -LT or even mayber -59 for the opposite foot (if both feet are done). Sometimes the rules and guidelines simply don't seem logical. :eek:
 
These are toes and not feet, and the code is for multiple toes which means any number 2 thru 10, toes do not have laterality, they are each separate or as in this code all together.
 
28011 should be billed for this procedure with the t modifiers
the code is for each toe with multiple tendons

Medicare will only pay 5 lines with the 6th - 10th by appeal and op note.

You wouldn't want to bill it with a 50 because its each toe and not feet

Hope this helps:)
 
I looked at the code a second time here and you are correct it is for multiple tendons on each toe. Subtle but true! I am not sure why you are having issues with Medicare past the 5th line. I have never had an issue with billing 10 toes or 10 fingers for my hand surgeons, you do need to submit a multi page claim, you put the page numbers on (software should do this) and you total the charges on the last page only. I do this several times a week in three different states and never had any issue with Medicare or any other payer.
 
Back in 2008 there was an AMA response that stated the CDR was incorrect in their publication for CPT 28011. As indicated by the CPT code descripter 28011 is for multiple tendons not multiple "toes". For instance one tendon release in one toe would be reported 28010 with the toe modifier. If you have ONE tendon in two different toes(2nd and 3rd digit right) this would report as 28010-T6 and 28010-T7. (one tendon in each toe) .

Somtimes they may release 2 seperate tendons in the 3rd toe right, 28011-T7(MULTIPLE TENDONS IN ONE "TOE")

The CPT descipter for 28010 is "toe", singular not "toes"
 
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