Hammertoe Correction (28285 & 28232) – Billing Tips

Hammertoe correction procedures are among the most common surgical services podiatrists perform, but billing them correctly can be tricky. Understanding the differences between CPT codes 28285 and 28232, along with proper documentation and modifier use, is essential for accurate payment and avoiding claim denials. Here are some indispensable billing tips to help you navigate hammertoe correction coding.

Understanding the Code Differences

CPT 28285 describes the correction of hammertoe with interphalangeal fusion. This code is used when you perform an arthrodesis (fusion) of the proximal interphalangeal (PIP) joint or distal interphalangeal (DIP) joint. The procedure typically involves removing cartilage from the joint surfaces, preparing the bone, and fixing the joint with pins, screws, or other internal fixation devices to achieve fusion.

CPT 28232 describes a tenotomy procedure for the correction of hammertoe. This is a tendon-cutting procedure without fusion. It’s a less invasive approach that involves releasing tight tendons or performing a flexor tenotomy to allow the toe to straighten. This code is also used for simple arthroplasty procedures that don’t involve fusion.

The key distinction is whether you’re performing a joint fusion (28285) or just releasing tendons without fusion (28232). Your operative report must clearly document which procedure you performed to support your code selection.

Documentation Requirements

Proper documentation is your best defense against claim denials and audits. Your operative note should include specific details that justify your code selection:

For CPT 28285, document the following elements:

• Which joint you fused (PIP or DIP)
• How you prepared the joint surfaces
• What type of fixation you used (K-wire, screw, etc.)
• The technique used to achieve fusion
• Any bone grafting if applicable

For CPT 28232, clearly document:

• Which tendons were released
• The surgical approach and technique
• Why was fusion not necessary
• Any arthroplasty performed

Generic language like “hammertoe correction performed” is insufficient. Payers want to see the specific surgical steps that support the code you’re billing. Think of your operative report as telling the story of what you did and why you did it.

Bilateral Procedures and Modifier 50

When you correct hammertoes on both feet during the same operative session, you need to use modifier 50 (bilateral procedure). However, there’s an important catch: modifier 50 should only be used when you perform the identical procedure on both sides.

For example, if you perform 28285 on the second toe of the right foot and 28285 on the second toe of the left foot, you would bill 28285-50. Most payers will reimburse the bilateral procedure at 150% of the unilateral fee (100% for the first side, 50% for the second side).

If you’re performing different procedures on each foot or on different toes, you shouldn’t use modifier 50. Instead, use modifiers RT (right) and LT (left) along with modifier 59 or XS on the second procedure to indicate they’re distinct services.

Multiple Toe Corrections and Modifier 51

When you correct multiple hammertoes on the same foot during the same operative session, you need to understand how to properly stack your codes with modifier 51 (multiple procedures).

List the highest RVU (relative value unit) procedure first without a modifier. Then list subsequent procedures with modifier 51 appended. Most payers will reduce payment for the second through fifth procedures according to the Medicare multiple procedure payment reduction (MPPR) rules:

• First procedure: 100%
• Second procedure: 50%
• Third through fifth procedures: 50%

For example, if you correct hammertoes on the second, third, and fourth toes of the right foot, all with fusion, you would bill:

• 28285-T1 (second toe, 100% payment)
• 28285-51-T2 (third toe, 50% payment)
• 28285-51-T3 (fourth toe, 50% payment)

The T modifiers (T1, T2, T3, etc.) help specify which toe you operated on, which is particularly important for accurate documentation and any potential follow-up care.

Mixing Fusion and Non-Fusion Procedures

It’s not uncommon to perform fusion on some toes and tendon releases on others during the same operative session. When mixing 28285 and 28232, remember that 28285 typically has a higher RVU value, so it should be listed first.

For instance, if you perform fusion on the second toe and a tenotomy on the third toe of the right foot, you would bill:

• 28285-T1 (fusion on second toe, 100% payment)
• 28232-51-T2 (tenotomy on third toe, 50% payment)

Your operative report must clearly differentiate what was done on each toe to support billing different codes.

Common Billing Mistakes to Avoid

Mistake 1: Using the wrong code for the procedure performed. Make sure your operative note supports the code. If you only released tendons but billed for fusion, expect a denial or potential audit issue.

Mistake 2: Failing to use anatomical modifiers. T modifiers help specify which toe received which procedure. This is crucial for multiple toe corrections and for potential future care.

Mistake 3: Not documenting medical necessity. Your preoperative notes should clearly explain why the patient needed surgical correction, including failed conservative treatment, functional limitations, and how the deformity was affecting the patient’s quality of life.

Mistake 4: Incorrect modifier usage. Using modifier 50 when procedures aren’t truly bilateral or forgetting modifier 51 on secondary procedures can result in claim processing errors.

Mistake 5: Bundling issues. Be aware of what’s included in your hammertoe correction code. Closing the surgical site, local anesthesia, and routine postoperative care are bundled and shouldn’t be billed separately.

Pre-Authorization and Medical Necessity

Many insurance plans require pre-authorization for elective surgical procedures like hammertoe correction. Before scheduling surgery, verify the patient’s benefits and obtain any necessary authorizations.

Document conservative treatment failures in the patient’s chart. Most payers want to see that you tried non-surgical options such as padding, taping, shoe modifications, orthotics, or other conservative measures before proceeding to surgery. A good rule of thumb is to document at least three months of conservative care, though this varies by payer.

Your preoperative documentation should include:

• Severity of the deformity (flexible vs. rigid)
• Functional limitations (difficulty walking, pain with shoes)
• Failed conservative treatments with dates
• Clinical examination findings
• Radiographic evidence of the deformity

Coding for Fixation Devices

The surgical fixation devices used during hammertoe fusion (K-wires, screws, plates) are typically included in the surgical code and shouldn’t be billed separately. However, some facilities may track these for supply reimbursement purposes.

If you’re billing in a facility setting, make sure the facility knows what hardware you used so they can properly bill for supplies. In your office surgical suite, the cost of these devices is included in your overhead and covered by the facility fee component of your reimbursement.

Follow-Up and Global Period Considerations

Hammertoe correction procedures have a 90-day global period under Medicare and most commercial payers. This means your surgical fee includes all routine postoperative care for 90 days after surgery. You cannot bill separately for routine follow-up visits during this period.

However, if the patient develops a complication or has an unrelated problem during the global period, you may be able to bill for those services using modifier 24 (unrelated E/M during global period) or modifier 79 (unrelated procedure during global period), depending on the situation.

Final Thoughts

Accurate billing for hammertoe corrections requires attention to detail in both your surgical documentation and your coding practices. Take time to write thorough operative reports that clearly describe what you did, use appropriate modifiers to indicate multiple procedures and bilateral surgeries, and document medical necessity in your preoperative notes.

When in doubt, consult the current CPT manual, check payer-specific policies, and consider working with a certified coder who specializes in podiatry. Proper coding not only ensures appropriate reimbursement but also protects you from audits and compliance issues. Staying current with coding changes and payer requirements is an ongoing responsibility that pays dividends in your practice’s financial health.

FAQs

What’s the main difference between CPT codes 28285 and 28232? 

CPT 28285 is for hammertoe correction with joint fusion (arthrodesis), while 28232 is for tendon release (tenotomy) without fusion.

How do I bill when correcting hammertoes on multiple toes of the same foot? 

List the highest RVU procedure first without a modifier, then add modifier 51 to subsequent procedures, using T modifiers (T1, T2, T3) to specify which toe.

When should I use modifier 50 for bilateral hammertoe procedures? 

Use modifier 50 only when performing the identical procedure on the same toe of both feet during the same operative session.

What documentation is needed to support medical necessity for hammertoe surgery? 

Document at least three months of failed conservative treatment (padding, orthotics, shoe modifications), functional limitations, deformity severity, and clinical/radiographic findings.