December 2003 Bulletin

Accurately code foot and ankle procedures

Learn instructions and examples

By Margie Scalley Vaught, CPC, CCS-P, MCS-P and reviewed by Walter J. Pedowitz, MD

AAOS members have requested on a number of occasions that the Bulletin cover foot procedures that might be lacking a correlation to CPT codes. In this issue, we respond to those requests and will discuss several procedures and corresponding CPT codes.

Lisfranc fracture/dislocation
This type of injury can be consistent with a fracture accompanied by dislocation of the tarsometatarsal (Lisfranc) joint located in the middle of the foot. This injury can be caused by a high-energy blow to the foot or by a twisting fall. (Lisfranc was a surgeon in Napoleon’s army; thus, the name is based on his description of the injury suffered by a soldier who fell off a horse with his foot trapped in the stirrup.)

The mechanism of the injury causes the tarsal bones to dislocate with or without resulting metatarsal (MT) fractures. Many times, both the dislocation and the fracture are treated separately with stabilization devices, which can be closed, percutaneous or open. Separately coding for the fixation of the metatarsal fractures could depend on the location of those fractures. Lisfranc dislocation can be for one or many of the tarsometatarsal joints. The open reduction code is for each joint that is reduced in an open fashion. Here are some examples:

Pump bump
Whether called “pump bump” (for association of shoe pumps causing irritation on the back of the heel), Haglund, bone spur or exostosis of the calcaneous, is normally the same CPT code 28118. Excision of a bone spur through the Achilles tendon can also be reported using 28118 because the attaching or reattaching of the Achilles tendon to get to this spur would be considered inherent in the removal of the spur. CPT code 28118 represents, “Ostectomy, calcaneus.” Now CPT code 28119 represents, “Ostectomy, calcaneus; for spur, with or without plantar fascial release,” which would be reported when there is a spur on the bottom of the foot and a plantar fascial release may also be performed.

Hammertoes
Hammertoe corrections are reported with CPT code 28285. The AAOS Complete Guide to Global Service Data, (2003 edition) states the following procedures would be considered/included in the reporting of 28285:

As indicated above, the internal fixation is included in the procedure. This refers to K-wires or other devices that are used to stabilize the toe. Remember that the removal of the K-wires during the postoperative period would normally be considered inherent in their placement and thus additional coding would not take place. Even though the K-wires are buried just under the skin and a small incision is made to remove them, they are buried for patient comfort and protection.

What is not included in the hammertoe corrections is 28270— capsulotomy of the metarsalphalangeal (MTP) joint as this is in a different joint location.
Posterior malleolar fractures

The reference to posterior malleolar fractures has caused some coders concern because there is not a specific CPT code that states posterior malleolus. There are codes for lateral, medial, bimalleolar and trimalleolar but none that specifically states posterior. The distal tibia has a large flat articular surface (the plafond), a prominent medial malleolus and a less prominent posterior malleolus. Fixation of the posterior malleolus is normally performed when more than 30 percent of the joint surface is involved. Many times these injuries are also associated with other malleolar fractures. There are CPT codes that deal with the distal tibial plafond:

27824 Closed treatment of fracture of weight-bearing articular portion of distal tibia (eg, pilon or tibial plafond), with or without anesthesia; without manipulation

27825 Closed treatment of fracture of weight-bearing articular portion of distal tibia (eg, pilon or tibial plafond), with or without anesthesia; with skeletal traction and/or requiring manipulation

27826 Open treatment of fracture of weight-bearing articular surface/portion of distal tibia (eg, pilon or tibial plafond), with internal or external fixation; of fibula only

27827 Open treatment of fracture of weight-bearing articular surface/portion of distal tibia (eg, pilon or tibial plafond), with internal or external fixation; of tibia only

Cheilectomy
CPT code 28289 represents “Hallux rigidus correction with cheilectomy, debridement and capsular release of the first metatarsophalangeal joint (MTP).” Many have taken this to mean that this CPT code could not be used if the cheilectomy was performed for degenerative arthritis of the first MTP joint. In fact, you will find that many CPT and ICD-9 linkage software will show that the only diagnoses that can be reported with this procedure is that of hallux rigidus.

Hallux rigidus is synonymous with arthritis, but many offices have continued to default to reporting the one ICD-9 code 735.2 hallux rigidus—when in actuality, reporting the appropriate arthritis ICD-9 code should be used when the medical record reflects this. The actual cheilectomy surgical procedure is that of removing a lump or spur on the top of the main joint of the big toe. Because bone spurs can be caused by arthritis, this CPT code represents that surgical procedure.

Understanding the CPT language of a given CPT procedure code can be difficult at times because surgeons don’t always speak, “CPTism.” Thus, proper code selection can become a problem.

When it comes to coding and reporting foot and ankle procedures, coders and surgeons must work as a team to assign the appropriate CPT and ICD-9 codes based on supporting documentation. Orthopaedic surgeons should be aware of the code descriptions and supply the appropriate wording to support the selection.

CPT and ICD-9 guidelines both state that if generic or unclear descriptions are provided, coders are to go back to the physician for further clarification. Documentation is the key element in compliance, as well as in coding and reimbursement. Working as a team can alleviate extra coding steps, if documentation is clearly cited.

References
CPT 2003 Professional Edition, American Medical Association
ICD-9-CM Coding Manual 2003
AAOS Complete Guide to Global Service Data
, 2003 edition

Margie S. Vaught, CPC, CCS-P, MCS-P, is an independent coding specialist in Ellensburg, Wash. She is also a member of the American Academy of Professional Coders’ National Advisory Board. She can be reached at vaught@kvalley.com

Walter J. Pedowitz, MD, is a foot and ankle specialist at the Union County Orthopedic Group in Linden, N.J., and a clinical professor of orthopaedic surgery at Columbia University in New York. He is also a member of the AAOS CPT and ICD coding committee. He can be reached at (908) 486-1111 or ped4feet@comcast.net.


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