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Question Coding Lisfranc Dislocations by Primary Arthrodesis

wgore18

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Good afternoon,
Our practice has recently had several Lisfranc surgeries and I wanted to seek out advice to ensure we were billing them correctly. Any responses to either of my questions for these types of surgeries would be greatly appreciated!

One of the recent surgeries involved a Lisfranc dislocation of all five of the tarsometatarsal joints as well as one of the midtarsal joints. The surgeon treated these injuries by fusing the first TMT joint, fusing the second TMT joint, fusing the third TMT joint, fusing the midtarsal joint, and doing manual reduction of the fourth and fifth TMT joints without fusion or internal fixation.

For the services she listed the following codes:
28730 x3 [Arthrodesis; midtarsal or tarsometatarsal, multiple or transverse]
28730 x1 [Arthrodesis; midtarsal or tarsometatarsal, multiple or transverse]
28615 x5 [Open treatment of tarsometatarsal joint dislocation, includes internal fixation, when performed]

From that list of codes, and after review of available information, these are the codes I feel comfortable with submitting:
28730 x1 [Arthrodesis; midtarsal or tarsometatarsal, multiple or transverse] 1st, 2nd, and 3rd TMT and Midtarsal fusions
28615 x2 [Open treatment of tarsometatarsal joint dislocation, includes internal fixation, when performed] 4th and 5th TMT

My reasoning for reducing the units of 28730 was that the code states "multiple" in the description so it felt incorrect to be billing multiple units for the separate joints. I do have a question about this code, though. Since the code description specifies "or" instead of "and/or", would it be appropriate to bill a code for the midtarsal arthrodesis such as "28740: Arthrodesis, midtarsal or tarsometatarsal, single joint" separate from 28730 for the TMT arthrodeses?

My second question is: if a dislocation is treated by arthrodesis [28740], is it appropriate to also bill open treatment of the dislocation [28615]? I haven't seen any resources endorsing this but it also is consistently listed in the op notes for several of my providers. If the dislocation and arthrodesis cannot be billed for the same joint, it feels like the work of the provider is getting undercut. The work for treating multiple dislocations with arthrodesis would fall under a single 28730 even though, in a similar scenario, the same joint dislocations treated without arthrodesis would receive multiple units of 28615, resulting in significantly higher reimbursement for the less work.

Thank you for reading,

Wesley
 

Orthocoderpgu

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Salt Lake City, UT
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Coding Lis-Franc fractures/dislocations is probably the most challenging to code. The reason for this is that unlike most other surgical repairs, Lis-Francs are always unique and rarely are two of them the same. The surgical procedures are going to vary significantly from to one another which makes coding them anything but routine. If you look at code 28730 it has an MUE of "one" and an MAI "2 policy" which means that you cannot bill more than one unit, period. Some MUE's can pay more than the allotted when medical records support them, but this is not one of them. If there are any coding supervisors/managers reading this please be advised that Lis-Franc coding is never "cookie cutter" and at least twice the allotted time will be necessary in order to code these correctly.
 
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