“Do you have any advice on coding for a return to the operating room within the 90-day postoperative global period for revision of the prior procedures that were performed? The patient had a 1st metatarsocuneiform joint (MTCJ) fusion and 2nd toe, proximal interphalangeal joint (PIPJ) fusion for a hammertoe. Post op x-rays demonstrated excellent fixation and alignment. The patient returned 2 weeks later and had obvious abnormal clinical changes to position of the fusions. X-rays showed loss of position correction at the 1st MTCJ fusion and the 2nd toe fusion as the two-component implant had disengaged and dislocated. The patient didn’t recall any injury. This required a return to the OR for revision of the fusion of both joints done three weeks post operative. The 1st MTCJ plate and screws were removed, the joint realigned and a new plate/screw construct applied. The 2nd toe PIPJ was opened, and the two-component implant re-engaged for alignment correction. Is the following coding scenario 28740 -78, CPT 28285 -78 correct to bill?”
So, a patient had two procedures performed on the same foot on the same date of service. The two procedures that were performed are the following:
First metatarsocuneiform joint fusion. This is coded with CPT 28740 which is defined as the following: Arthrodesis; midtarsal or tarsometatarsal, single joint.
Second toe proximal interphalangeal joint (PIPJ) fusion. This is coded with CPT 28285 which is defined as the following: Correction, hammertoe (e.g. interphalangeal fusion, partial or total phalangectomy).
Two weeks into the 90-day postoperative global period, the patient returned, and X-rays revealed that there was a failure of the fusions that were performed at the first metatarsocuneiform joint and at the PIPJ of the 2nd toe. The patient needed to return to the OR and have both arthrodesis procedures revised. The hardware that was initially placed within both surgical sites needed to be removed and the fusions needed to be repeated at both surgical sites. How would the subsequent procedures be coded?
Since the removal of the hardware cannot be billed for based upon the fact that the two arthrodesis procedures were repeated and new hardware was administered within both surgical sites, I would agree that the coding scenario would be the following:
CPT 28740 – RT/LT, 78
CPT 28285 – T6/T1, 78
The 78 modifier is defined as the following: UNPLANNED RETURN TO THE OPERATING/PROCEDURE ROOM BY THE SAME PHYSICIAN FOLLOWING INITIAL PROCEDURE FOR A RELATED PROCEDURE DURING THE POSTOPERATIVE PERIOD aka “Complication Modifier”- It may be necessary to indicate that another procedure was performed during the postoperative period of the initial procedure (unplanned procedure following initial procedure). When this procedure is related to the first and requires the use of an operating or procedure room, it may be reported by adding modifier 78 to the related procedure.
This coding scenario would be my first choice.
It is possible that the health insurance carrier in question might take the position that despite the fact that the second set of procedures needed to be performed due to the complications that arose within the 90-day postoperative global period, in reality what was performed was the repeat of the same set of procedures. This leads to coding scenario #2:
CPT 28740 – RT/LT, 76
CPT 28285 – T6/T1, 76
The 76 modifier is defined as the following: REPEATED PROCEDURE BY THE SAME PHYSICIAN – It may be necessary to indicate that a procedure or service was repeated subsequent to the original procedure or service. This circumstance may be reported by adding modifier 76 to the repeated procedure or service.
This coding scenario would be my second choice.
This is my opinion.
Michael G. Warshaw
DPM, CPC
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