The Angel Of the South
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For practicode. The pt had a partial left great toe amputation. I coded modifier 52 because it said partial. But the rationale says the only modifier is TA to identify the toe.
For practicode. The pt had a partial left great toe amputation. I coded modifier 52 because it said partial. But the rationale says the only modifier is TA to identify the toe.
My correct CPT code was 28825. The documentation says:Which CPT code was used? I believe there are multiple toe amputation codes, with the difference being what joint the amputation occurred at.
If the definition of the CPT code already defined what joint the toe was removed at & the code already demonstrated a partial removal, a separate modifier wouldn't be necessary.
(That's the best I can speculate without knowing the code & how the documentation was worded.)
PREOPERATIVE DIAGNOSIS: Gangrene of the left great toe
POSTOPERATIVE DIAGNOSIS: Gangrene of the left great toe.
PROCEDURE PERFORMED: Left great toe partial amputation through the proximal interphalangeal joint with primary closure.
ANESTHESIA: General endotracheal.
INDICATION: This is a gentleman with Type 2 diabetes and other medical problems who developed gangrene of the left great tip toe. Arterial studies demonstrate a normal perfusion of the left foot. The gangrene has progressed slightly to involve the mid portion of the great toe. The patient presents today for a left great toe partial amputation. The risks, benefits, and alternatives of the procedure were discussed with the patient who understands and is in agreement to proceed.
DESCRIPTION OF PROCEDURE: The patient was brought to the operating room and laid supine on the table. After general endotracheal anesthesia was established, the left foot was then prepped and draped in the standard surgical fashion. The patient was given 2 g of IV Ancef prior to incision.
A circumferential incision was made along the healthy skin proximal to the area of gangrene in the mid left great toe with a #10 blade. Dissection was carried down through the subcutaneous tissues with the 15 blade. The tendons and tissues were divided with the 15 blade. The specimens handed off. The middle phalanx bone was also trimmed back to the proximal interphalangeal joint and removed entirely. The wound was then cleansed of any necrotic tissue. The wound was copiously irrigated with antibiotic solution. The subcutaneous tissues were reapproximated over the proximal phalanx with interrupted 3-0 Vicryl sutures. The wound was cleansed and dried. Xeroform with 4x4s and Kerlix wrap was applied. The patient was subsequently awakened and taken to the PACU in stable condition. The sponge, instrument, and needle counts were correct at the end of the case. I was present for the entire case.
My correct CPT code was 28825. The documentation says: