“I had a patient present to the clinic with multiple, minimally displaced toe fractures. She has Medicare and we are planning to treat all four of these conservatively. When and how do I use CPT code 28510?”
So, a patient had multiple, minimally displaced toe fractures. The treatment plan is to treat the four, minimally displaced digital fractures conservatively. That could consist of placing the patient in a surgical shoe, strapping the toes together to immobilize them, etc. The CPT code that was selected and appropriately so is CPT code 28510 which is defined as: Closed treatment of fracture, phalanx or phalanges, other than great toe; without manipulation, each.
The good news is that the Medically Unlikely Edits for CPT code 28510 is 4. That means that CPT code 28510 can be billed a maximum of 4 times on a given date of service. Theoretically. Now we are talking about Medicare. I would suspect that the Medicare Advantage Plans and the commercial health insurance plans would follow the same line of thinking.
Now for the bad news. Since all four of the fractured toes are on the same foot, the treatment plan, whether it is placing the affected foot in a surgical shoe, strapping the affected toes together or perhaps even placing the affected foot in CAM walker boot, essentially treats ALL of the fractures simultaneously. There is no individuality here. Therefore, assuming that CPT code 28510 is going to be used appropriately. It should be billed only once or at 1 unit.
Of course, I would be not doing my job if I did not provide hard copy proof for the above information. Well, here it is.
The reference is NCCI or the National Correct Coding Initiative. Whether the insurance is Medicare, or private insurance, both use NCCI as a source to limit reimbursements by essentially bundling procedures together. You can only bill for 1 closed fracture without manipulation in this scenario. In Chapter 4 of the NCCI Manual, it states: “If a single cast, strapping, or splint treats multiple closed fractures without manipulation, only one closed fracture treatment without manipulation CPT code may be reported.”
This is my opinion.
Michael G. Warshaw
DPM, CPC
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