“I have a patient who had a hammer toe deformity, and this required repair of the second toe. Unfortunately, the surgical site developed osteomyelitis. This complication occurred at postoperative week number four. I returned to the operating room to perform an amputation of the second toe because of osteomyelitis. I would like to hear thoughts on the appropriate modifiers. And how does the zero-day global period for the amputation play into the billing for the post operative care?”
The primary procedure that was performed was the repair of the hammertoe deformity of the 2nd toe. The appropriate code to bill is CPT 28285 which is defined as the following: Correction, hammertoe (e.g. interphalangeal fusion, partial or total phalangectomy), appended by the correct digital/toe modifier. This is classified as a major surgical procedure/CPT code that has a postoperative global period of 90 days.
Unfortunately, during the postoperative global period at week four, a complication developed, specifically osteomyelitis at the surgical site. This necessitated a return to the operating room to perform an amputation of the 2nd toe. I am assuming that this was performed at the 2nd metatarsophalangeal joint. What is the proper coding scenario?
The appropriate CPT code to bill is CPT 28820 which is defined as the following: Amputation, toe; metatarsophalangeal joint. This would be appended by both the appropriate digital/toe modifier and the 78 modifier which 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.
As far as the postoperative global period is concerned for the amputation of the 2nd toe, CPT 28820 has a postoperative global period of “0.” If CPT 28820 was performed as a free-standing procedure, so to speak and it was not performed within the postoperative global period of a previously performed procedure that it is directly related to, then all of the postoperative encounters/visits following the performance of CPT 28820 could be billed with the most appropriate E/M code as long as it was supported by medical necessity. Unfortunately, since the amputation of the 2nd toe was performed as the result of a complication to the hammertoe correction of the same, 2nd toe, the postoperative visits for the amputation of the 2nd toe would fall within the 90 day postoperative global period of the original procedure, the hammertoe correction and are not separately reimbursable. Sorry.
This is my opinion.
Michael G. Warshaw, DPM, CPC
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