“How would you code this? I’m stumped.
Operation 1. Attention was directed to the medial aspect of left great toe where an incision was made overlying the interphalangeal joint. The incision measured about 3-4 cm in length, the incision was deepened via sharp and blunt dissection, careful attention paid to all neurovascular structures appropriately retracted as necessary. The incision was carried down to bone, the soft tissue was freed from the medial side of the bone at the IPJ. The long flexor tendon was reflected plantarly. The accessory bone was found on the left and seemed to be adherent to the phalanx. It was removed and sent to pathology. The wound was flushed. C-arm radiograph taken pre and post to be sure that the bone had been removed. It was. The flexor tendon was reapproximated and maintained using 2-0 Vicryl, skin closure with 2-0 Vicryl. 4-0 Prolene.
Operation 2. Same, right foot
Operation 3. Attention was directed to the ulcer of the left great toe, 2 converging semielliptical incisions made surrounding the ulcer, excised and sent to pathology. There was necrotic tissue and debris within it. This was sent as well. The wound was flushed and closure performed using 2-0 Vicryl, 4-0 Prolene.
Operation 4. Same, right great toe
The doctor coded it as follows: CPT 28315-50, CPT 11422-TA, CPT 11422-T5.”
This is an interesting scenario. With respect to the accessory bones that were present and removed from both great toes, the CPT code that was billed is 28315 which is defined as: Sesamoidectomy, first toe (separate procedure). This CPT code is designated to be used for the excision of either the tibial or the fibular sesamoid that is present beneath the head of the 1st metatarsal. This accessory bone was located adjacent to and adherent to either the distal or the proximal phalanx at the IPJ of the great toe. The most appropriate CPT code to bill for the excision of this abnormality is 28124 which is defined as: Partial excision (craterization, saucerization, sequestrectomy, or diaphysectomy) bone (e.g. osteomyelitis or bossing); phalanx of toe. Based upon the op note (ie. Operation 1 and Operation 2), this procedure was performed on both great toes. With respect to the long flexor tendon, it was reflected and reattached in order to gain access to the accessory bone. Therefore, it is incidental to the procedure that was performed and is not separately reimbursable.
As far as the ulcer that was present on both great toes, this needs to be looked at a bit more carefully. There is no mention within the operative note where anatomically the ulcer is located. I am also making the assumption that there is an ulcer on both great toes in exactly the same location. If the ulcer was not associated with the accessory bone within the great toe and the incision that was made to access the accessory bone was not through or adjacent to the ulceration, then the excision of the ulcer and the excision of the accessory bone would be distinct procedural services and would be separately billable and reimbursable. However, if the excision of the ulcer and the excision of the accessory bone were anatomically related in any fashion, then the excision of the ulcer would be inclusive to the procedure to excise the accessory bone and would not be separately reimbursable.
There is not a specific CPT code for the excision of an ulcer. However, if an ulcer is categorized or identified as a pressure ulcer, the correct CPT code for an excision and closure of an ulcer on the foot, ankle, or toes is CPT 15999 (Unlisted procedure, excision pressure ulcer). The more specific codes within the same series of CPT 15999 (15920-15958), do not apply to podiatry as they are for wound care around the lower back, thighs, and hips. Therefore, the unlisted CPT code would be appropriate. However, in general, ulcers on the toes are classified as non-pressure ulcers. I feel that based upon the excised diameter of the ulcer, the most appropriate CPT code set to use for the excision of a non-pressure ulcer would be CPT 1142X based upon the excised diameter of the lesion in question, in this situation, the ulcer. Unfortunately, the excised diameters of the two ulcers in question were not documented within the operative note.
In closing, if the ulcer was not related to the underlying accessory bone, the coding scenario would be the following:
CPT 28124 – T5
CPT 1142_ – 59, T5
CPT 28124 – TA
CPT 1142_ – 59, TA
If the ulcer and the underlying accessory bone were related, the coding scenario would be the following:
CPT 28124 – T5
CPT 28124 – TA
This is my opinion.
Michael G. Warshaw
DPM, CPC
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