Wiki need help coding this bunion procedure

Lunap99

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I need some help coding this foot surgery. Procedure was done in 2019 and we are still dealing with it. The provider has chosen the following codes:
code Denial
28298
28313-59 N206, CO-50
28740-51-59 M80, CO-97
28285-59-T6
20926-51-59 N206, CO-50
76000-26-59 N20, C-97

So I realize that there are directional modifiers missing and that 76000 is probably not going to be paid regardless. My questions refer to the codes used. I don't think the provider chose the best codes but I'm having a hard time determining which bunion codes to use. Any insight would be appreciated.
 

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I believe the codes billed are duplicating the procedures performed and are being correctly bundled and denied.

28297-RT (modifier dependent on the payer) bunionectomy with 1st met/cuneiform arthrodesis--that takes care of procedure 1 & 2--M20.11 or M21.6x1
28308-59 Osteotomy, with or without lengthening, shortening, or angular correction, metatarsal; other than first metatarsal, each M21.6x1
28313-T6-59 Reconstruction, angular deformity of toe, soft tissue procedures only (eg, overlapping second toe, fifth toe, curly toes) M24.374 these codes cover procedures 3 & 4

I agree that the 76000 is not payable and I cannot find 20926 as it was deleted in 2020 but it was for graft placement. I believe he/she was using this for the platelet rich plasma which is not a graft and cannot be billed as such, there is no code for PRP yet (it's in the works), it's usually billed as cash or bundled with the other procedures.

I hope that helps!!
 
Disagree with both coding choices above.

My opinion on the CPT:
28299 RT (some payers want T5 Right foot, great toe, but you're technically only supposed to use the T mods on phalanges) (If provider disagrees code 28297)
28285 T6 (59 mod depending on payer, possibly use XS mod. However, the T6 Right foot, second digit indicates anatomic specificity but in the real world it will deny without the 59)
28313 T6 (59 mod depending on payer, possibly use XS mod)

Why?
This procedure was a combination of two hallux valgus corrections: osteotomy and arthodesis. I can see why the two choices above have the codes they do but they are not correct. The first example is trying to use individual codes when there are more specific and unbundling codes. The second suggestion is close but not correct. 28308 is other than 1st metatarsal. The osteotomy done in this case was on the 1st proximal phalanx.
Per CPT 28299 is reported when combined methods are used. On page two of the op report the tendons are freed, ligaments transected and MTP capsulotomy performed. Then, the arthrodesis of the metatarsocuneiform is performed (which if performed alone would be 28297). On page three it is indicated there is still hallux abductus so proximal phalanx osteotomy of the RT great is done (this would be 28298 if done alone). Because it was a combo technique you code to 28299. I know it sounds crazy because the CPT 28299 description says double osteotomy, but it's because it was a combo of two techniques. If the provider doesn't agree I would just use 28297.

On page three the provider then moves to the second toe. Plantar plate repair is always a debated procedure. I have seen unlisted, 28313, 28270, 28272, etc. among the codes used. I feel it depends on the method and other procedures at the same area. This is a well presented plantar plate reference: https://www.apma.org/files/7 NYCC20 Coding Plantar Plate Repair SA.pdf

28285 hammertoe correction was performed on page three by K-wire throught he intermediate and distal phalanges and I would argue that is a different anatomic area than the plantar plate (28313) repair done at the second MTP joint.

You may find a payer denial of either the 28313 or 28285 as inclusive. Be sure to assign different diagnoses to each procedure and don't overlap them.

76000 is included because it has separate procedure designation meaning it is integral to these others and can't be reported separately (even with a 59 that's a red flag). It's also explained in the NCCI manual under "medical surgical package". The PRP placement is also included when used to promote healing at the site of a greater procedure. The "stuff" like the PRP kit would be a facility supply.
 
I see your point. This is good discussion. I would like to see if there are any other opinions.
I suppose you could also try 28297-22 for the extra work.

This is an old link but the concepts are still the same. Just keep in mind the CPT codes for bunions changed in 2017 so the code descriptions are not exactly the same.
"28299 - ; by double osteotomy There are two techniques described in the CPT book. One includes a proximal and distal osteotomy of the first metatarsal. The other example includes a distal osteotomy of the first metatarsal plus a base osteotomy of the attached proximal phalanx. AAOS states that this procedure includes: any combination of hallux valgus procedures (e.g. 28290-28298, 28485), includes all osteotomies of the first metatarsal and first proximal phalanx and allows additional coding and report for ankle tendon lengthening."



 
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