If a patient comes into the office/clinic and is diagnosed for example with a fracture at the base of the 5th metatarsal on the right foot and the physician eventually plans to operate on the fracture, there are a few options to explore and consider.
Option #1: With the assumption being that the fracture has occurred within the past 2 weeks, the best way to address this injury would be to perform open reduction with internal fixation (ORIF) as soon as possible (ASAP). Based upon this premise, the fracture would need to be immobilized and the alignment and the apposition of the fracture segments maintained until the ORIF could be performed. The patient would be placed in a pneumatic fracture walker and kept totally non-weight bearing (NWB) in order to keep the fracture site from worsening until the ORIF is performed. In this situation, it would not be appropriate to bill CPT 28470 which is defined as the following: Closed treatment of metatarsal fracture; without manipulation each based upon the fact that the fracture site is not being “treated” to promote healing at the fracture site, but rather to maintain the position of the fracture to prepare the fracture site for ORIF to be performed. In this scenario, the initial coding scenario would be:
CPT 99204
CPT 73630-RT.
Option #2: Once again, with the assumption being that the fracture has occurred within the past 2 weeks, the best way to address this injury would be to perform open reduction with internal fixation ASAP. In this scenario, the patient has suffered a Jones fracture and surgical intervention is inevitable. The problem is that the patient has several comorbidities and unfortunately is not able to have ORIF at the surgical site in a timely fashion. Therefore, it would be most appropriate to immobilize the fracture site by placing the patient in a pneumatic fracture walker and kept totally NWB until the procedure can be performed. In this instance. The integrity and the apposition of the fracture segments will be maintained and perhaps a certain degree of bone healing might occur in order to aid the healing process when the ORIF is performed. The initial coding scenario would be:
CPT 99204-57
CPT 73630-RT
CPT 28740-RT
As part of the documentation within the medical record, it is important to note that this is a “staged, related, pre-planned scenario” and at point “X” in the future, ORIF will be performed.
When the time arrives for the ORIF to be performed to address the Jones fracture at the proximal aspect of the 5th metatarsal on the right foot, the coding scenario would be the following:
CPT 28485 (Open treatment of metatarsal fracture, includes internal fixation, when performed, each) – RT, 58. The 58 modifier is defined as the following: STAGED OR RELATED SURGICAL PROCEDURE (“STAGED, RELATED, PREPLANNED”) – ) It may be necessary to indicate that the performance of a procedure or service during the postoperative period was planned or anticipated (staged); b) more extensive than the original procedure; or c) for therapy following a surgical procedure. Note: For treatment of a problem that requires a return to the operating or procedure room (e.g., unanticipated clinical condition or complication), see modifier 78.
This is my opinion.
Michael G. Warshaw
DPM, CPC
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