“On February 11, a patient has a transmetatarsal amputation. The patient is a non-compliant, diabetic. The site deteriorates weeks after he leaves the hospital. On March 24, he was readmitted for an infected at the amputation site. On March 26, the remaining 5 metatarsals stumps are removed, and the wound is kept open. How would you recommend coding for the 2nd surgery? What is the code for removing the 5 remaining metatarsal stumps?”
So, the original surgery that was performed took place on February 11th. A transmetatarsal amputation was performed. This procedure is billed using CPT code 28805 which is defined as: Amputation, foot; transmetatarsal. There is no indication within the post that this was a “staged, related, pre-planned scenario.” Therefore when the subsequent surgery was performed on March 26, the 58 modifier could not be appended which would indicate: STAGED OR RELATED SURGICAL PROCEDURE (“STAGED, RELATED, PREPLANNED”) It may be necessary to indicate that the performance of a procedure or service during the postoperative period was planned or anticipated (staged); b) more extensive than the original procedure; or c) for therapy following a surgical procedure.
The patient received further surgery March 26 on the affected foot due to an infection on the same foot specifically at the site where the transmetatarsal amputation was performed. The remaining 5 metatarsal stumps were removed. How would this be coded?
Since the remaining five metatarsal stumps were removed or amputated on this subsequent date of service, wouldn’t this still be classified as a transmetatarsal amputation? I believe that it would be. Problem #1 is that this CPT code was just billed on February 11. Problem #2 is that surgery #2 was performed due to the fact that a complication of surgery #1 arose. Here is what I feel would be the most appropriate coding scenario for the second surgery:
CPT 28805 – RT/LT, 76, 78
The definition of the 76 modifier is 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.
The definition of the 78 modifier is the following: UNPLANNED RETURN TO THE OPERATING/PROCEDURE ROOM BY THE SAME PHYSICIAN FOLLOWING INITIAL PROCEDURE FOR A RELATED PROCEDURE DURING THE POSTOPERATIVE PERIOD.
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.
Since the second amputation surgical site/wound was kept open, at point “X” in the future, delayed closure will need to be performed. If at the time of procedure #2 which was performed on March 26, it was stated in the medical record that this is a “staged, related, pre-planned scenario,” and delayed closure will be performed at the appropriate time, the 58 modifier will be able to be applied to CPT code 13160 (Secondary closure of surgical wound or dehiscence, extensive or complicated) when the delayed closure is performed. Once again, the 58 modifier is defined as: STAGED OR RELATED SURGICAL PROCEDURE (“STAGED, RELATED, PREPLANNED”) It may be necessary to indicate that the performance of a procedure or service during the postoperative period was planned or anticipated (staged); b) more extensive than the original procedure; or c) for therapy following a surgical procedure.
This is my opinion.
Michael G. Warshaw, DPM, CPC
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