“Has anyone had CIGNA, Tufts, UHC reject CPT code 28310 (Akin osteotomy) as a separate and billable code with a Lapidus arthrodesis/hallux valgus correction with bunionectomy (CPT 28297)? I did appeal with CIGNA and was told that the nurse-coder looked at my appeal and related to me that according to the NCCI Edits, the Akin osteotomy is “part and parcel” included with a Lapidus arthrodesis/ bunionectomy. What is the next step?”
If a hallux valgus correction with bunionectomy is performed, specifically the removal of the medial aspect of the head of the 1st metatarsal and an arthrodesis is performed at the base of the 1st metatarsal articulation with the medial cuneiform, the correct code to bill is CPT 28297 which is defined as the following: Correction, hallux valgus with bunionectomy, with sesamoidectomy; when performed, with first metatarsal and medial cuneiform arthrodesis, any method. In this case, an osteotomy needs to be performed within the proximal phalanx of the great toe to properly align the 1st metatarsal-phalangeal joint. The correct code to bill is CPT 28310 which is defined as the following: Osteotomy, shortening, angular or rotational correction; proximal phalanx, first toe (separate procedure). When the NCCI edits are accessed, CPT 28310 is the Column 2 code to CPT 28297 the Column 1 code. Therefore, one would think that these two CPT codes are bundled and only CPT 28297 would be appropriate to bill.
There is more to the story. Taking this one step further, there are modifier indicators that apply to every pair of CPT codes in order to determine whether it is appropriate to bill the Column 2 code with the Column 1 code. The modifier indicators are the following:
0 Codes are always bundled. Do not submit a modifier for exceptions.
1 Exceptions may apply. Submit the appropriate modifier (Note: Documentation is required in the patient’s medical record).
2 Not applicable. The code pair is no longer bundled, and no modifier is needed for purposes of noting an NCCI exception.
When the paring of CPT codes 28297 and 28310 is examined, the modifier indicator is “1 – Allowed.”
Therefore, I would certainly find it appropriate to bill the procedures that were performed in the following fashion:
CPT 28297 – RT/LT
CPT 28310 – 59, T5/TA
Based upon the rejection of the claim by CIGNA, Tufts, UHC, etc. due to CPT 28297 and CPT 28310 being bundled, I would so file an appeal. I would absolutely access the NCCI edits and explain to the “nurse coder” specifically what a modifier indicator of 1 is, and also explain what the 59 modifier is used for. It is used to indicate a distinct procedural service.
Wouldn’t the same surgical result be achieved if an Akin bunionectomy was performed in conjunction with a 1st metatarsal medial cuneiform arthrodesis? Of course, it would. Here are the two CPT codes involved:
CPT 28298 Correction, hallux valgus with bunionectomy, with sesamoidectomy, when performed, with proximal phalanx osteotomy, any method. This is the Column 1 code.
CPT 28740 Arthrodesis; midtarsal or tarsometatarsal, single joint. This is the Column 2 code.
Guess what? When the NCCI edits are accessed CPT 28298 and CPT 29740 are not bundled. Therefore, it would be appropriate to bill these 2 CPT codes together. The coding scenario would be the following:
CPT 28298 – RT/LT
CPT 28740 – 59, RT/LT
This sure looks like a viable option!
This is my opinion.
Michael G. Warshaw, DPM, CPC
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