Ray Resection Coding

[Adam Smasher]

---

Members don't see this ad.

How do you code your ray resections? I had a mutual patient with my friendly neighborhood Fellowship Trained Foot and Ankle Surgeon who did a partial first ray resection. His op note was as follows:

1. First metatarsal ostectomy
2. Amputation of hallux
3. Sesamoidectomy

Which sounds like a ray resection to me, 28810. I've heard the argument that because you're not resecting the entire ray, it's not appropriate to use 28810, which is why you technically have to unbundle it like that. I checked my coding manual which describes a 28810 specifically as dissecting the capsule of the TMT articulation and disarticulating the metatarsal which we almost never do. So is this unbundling right?

 

[Boba Foot]

28810 all day long. I’d be shocked if he got paid for blatant unbundling like that. Even including the sesamoidectomy is lol.

 

[Hybrocure]

Sesamoidectomy code is wild lmao

 

[Homo sapien]

Sesamoidectomy lol. Real TFP ****

 

[air bud]

How do you code your ray resections? I had a mutual patient with my friendly neighborhood Fellowship Trained Foot and Ankle Surgeon who did a partial first ray resection. His op note was as follows:

1. First metatarsal ostectomy
2. Amputation of hallux
3. Sesamoidectomy

Which sounds like a ray resection to me, 28810. I've heard the argument that because you're not resecting the entire ray, it's not appropriate to use 28810, which is why you technically have to unbundle it like that. I checked my coding manual which describes a 28810 specifically as dissecting the capsule of the TMT articulation and disarticulating the metatarsal which we almost never do. So is this unbundling right?

There's literally a code for resecting the entire metatarsal..... So that argument is BS. 28140. This is just what fellowship has come down to how to illegally bill.

 

[air bud]

And the thing that's so funny about a lot of this is when you are in a system where they have a 50 percent reduction.... And again we talked about that being better than the 5025-25 etc that PP gets.... You make more with less risk with just doing the full single code.... Like a TMA just take the TMA code it's 12.5 RV used That's going to be more than whatever BS way you're trying to do it with 50% reductions on everything else.

Yesterday I had a guy with a partial first Ray amputation full length second metatarsa partial third metatarsal, full length fourth metatarsal and a little bit of the proximal phalanx and full-length fifth metatarsal and proximal phalan..... Yes the X-ray looks as dumb as you can think it is but could I have done partial ray here partial ray there excision of bone there blah blah blah yeah it's just easier to take the TMA and take the full 12.5 and just be done with it.... Plus it was a t-shaped incision to get it closed after exercising the ulcer so it was a rotational soft tissue flap so just take what you can get

 

[Hybrocure]

Sesamoidectomy lol. Real TFP ****

Not TFP honestly. This is fellowship trained unbundling 101. Every hotshot surgeon in town has op reports with 20 codes for a $1500 case if billed properly at best with the 1 or 2 codes it should be. Like I get it, surgery the way it is doesn’t pay us as much as it should. But billing out 30k+ for a foot case is nuts

 

[Hybrocure]

And the thing that's so funny about a lot of this is when you are in a system where they have a 50 percent reduction.... And again we talked about that being better than the 5025-25 etc that PP gets.... You make more with less risk with just doing the full single code.... Like a TMA just take the TMA code it's 12.5 RV used That's going to be more than whatever BS way you're trying to do it with 50% reductions on everything else.

Yesterday I had a guy with a partial first Ray amputation full length second metatarsa partial third metatarsal, full length fourth metatarsal and a little bit of the proximal phalanx and full-length fifth metatarsal and proximal phalan..... Yes the X-ray looks as dumb as you can think it is but could I have done partial ray here partial ray there excision of bone there blah blah blah yeah it's just easier to take the TMA and take the full 12.5 and just be done with it.... Plus it was a t-shaped incision to get it closed after exercising the ulcer so it was a rotational soft tissue flap so just take what you can get

Ah, rotational flap you say?

🤑

 

[Feli]

Ppl can try whatever they want.... doesn't mean it'll get paid (and might be later recouped if it is).

A simple look at the CPT manual and the pictures tells us a first ray amputation is 28810.
This kid probably got bad coding advice from one of his TFP attendings. There is common misconception on this (many people thought Goldsmith in link was an authority on coding... wrote a lot about it, not a surgeon). Unbundling like this he recommends was a lot more common decades ago; insurances have buttoned up nearly all of these loopholes, follow the MCR CCI edits now).

...the smarter (incorrect) coding on this first ray is just to do 28803 if you expect many visits in the global 90d.

 

[Retrograde_Nail]

How do you code your ray resections? I had a mutual patient with my friendly neighborhood Fellowship Trained Foot and Ankle Surgeon who did a partial first ray resection. His op note was as follows:

1. First metatarsal ostectomy
2. Amputation of hallux
3. Sesamoidectomy

Which sounds like a ray resection to me, 28810. I've heard the argument that because you're not resecting the entire ray, it's not appropriate to use 28810, which is why you technically have to unbundle it like that. I checked my coding manual which describes a 28810 specifically as dissecting the capsule of the TMT articulation and disarticulating the metatarsal which we almost never do. So is this unbundling right?

Podiatry fellowship training........................

 

[air bud]

Also all these fellowship train bros that got these amazing incredible hospital jobs doing all the foot and ankle trauma... Better check their contract. There's literally wording in my contract related to incorrect and abusive coding.

 

[Retrograde_Nail]

Also all these fellowship train bros that got these amazing incredible hospital jobs doing all the foot and ankle trauma... Better check their contract. There's literally wording in my contract related to incorrect and abusive coding.

That is why hospitals have coders to review the coding.

I have a personal hospital coder I literally talk to every day for coding cases. I've learned a lot

 

[Hybrocure]

“But ortho does it like this”

 

[heybrother]

 

[Boba Foot]

Honestly surprised they didn't bill 2 units on the sesamoidectomy at this point.

 

[MicroPod]

It’s simple, just remove one on first surgery and the other on the next surgery. Heck, just separate out all these things over a couple of weeks time and at the end DPC.

 

[Boba Foot]

It’s simple, just remove one on first surgery and the other on the next surgery. Heck, just separate out all these things over a couple of weeks time and at the end DPC.

Approved by the American Council of TFPs.

 

[Hybrocure]

It’s simple, just remove one on first surgery and the other on the next surgery. Heck, just separate out all these things over a couple of weeks time and at the end DPC.

The concept of doing DPCs for anything that isn’t pussed out gas or nec fasc is hilarious.

Yeah lemme just leave this open bone exposed in a hospital bacteria ridden environment instead of just closing primarily and getting them out of there asap

 

[air bud]

The concept of doing DPCs for anything that isn’t pussed out gas or nec fasc is hilarious.

Yeah lemme just leave this open bone exposed in a hospital bacteria ridden environment instead of just closing primarily and getting them out of there asap

Yes they grossly infected....that's why they are admitted to the hospital. They are on vanc/ cefepime, vanc/zosyn, vanc/ceftriaxone....they are fine in this bacteria ridden environment they are going to get MORE infected? CRP above 10ish.....DPC for sure. Yeah it is really hard to do for PP. Please let your friendly neighborhood hospital employed pod take care of all infection. Nobody ever regrets doing a DPC., plenty of regret not doing it. Plenty of return to OR, chronic wound care complications because Ortho closed up all at once. Regardless of billing, DPC ALWAYS good idea once you start cutting out metatarsals. Wait for finalization of cultures, return to OR, wash out cut out and close (see rotation).

 

[Hybrocure]

Yes they grossly infected....that's why they are admitted to the hospital. They are on vanc/ cefepime, vanc/zosyn, vanc/ceftriaxone....they are fine in this bacteria ridden environment they are going to get MORE infected? CRP above 10ish.....DPC for sure. Yeah it is really hard to do for PP. Please let your friendly neighborhood hospital employed pod take care of all infection. Nobody ever regrets doing a DPC., plenty of regret not doing it. Plenty of return to OR, chronic wound care complications because Ortho closed up all at once. Regardless of billing, DPC ALWAYS good idea once you start cutting out metatarsals. Wait for finalization of cultures, return to OR, wash out cut out and close (see rotation).

I’m moreso referring to toes and distal amps. In residency saw a lot of people getting admitted for distal toe osteo and doing the whole week plus stay with dpcs and out now in practice most of those amps I can do in office

 

[Homo sapien]

I’m moreso referring to toes and distal amps. In residency saw a lot of people getting admitted for distal toe osteo and doing the whole week plus stay with dpcs and out now in practice most of those amps I can do in office

How do you do it In office

 

[air bud]

How do you do it In office

I think about this in wound care....then say yeah this sounds like a pain in my butt. Local only in OR Friday add on as outpatient. Hospital across parking lot.

 

[Adam Smasher]

How do you do it In office

just rongeur off the tip little by little for your weekly 11044

kidding--back in the days of the 2am toe amputation discussion, I had this to say:

So I try not to discuss surgery on SDN because it's not what I'm on here to talk about but...

Toe amps in the OR are stupid even if it's 730am and the hospital serves you warm crepes in the lounge after. Ever since Medicare changed it to a zero day global, the reimbursement absolutely plummeted. I routinely amputate toes in the office where reimbursement justifies my time.

Inject anesthesia, sign consent, setup sterile instruments
Esmarch bandage around anke for tq
Betadine prep
Fishmouth incision, cut edl,fdl
Bone cutting forceps thru prox phalanx ($400 at medline)
Close

5min or 7 min if I want to send bone for culture. You can disarticulate too but it's more work (intrinsic tendons) and the skin doesn't heal as well over a clean met head vs bleeding trabecular bone.

You can't always do this, if it's terrible cellulitis with pus, closure is out of the question until they've had IV antibiotics. But if it's only a little red without much edema, you can just cut it off and give broad spectrum po antibiotics and avoid hospitalization completely in many cases.