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Understanding CPT Code 28505: Open Treatment of Fracture, Great Toe, Phalanx or Phalanges, with or Without Internal or External Fixation Explained

Medical coding is a crucial aspect of healthcare that ensures accurate documentation and billing for medical services. In this article, we will delve into the nuances of CPT code 28505, focusing on its application and the role of modifiers in specific scenarios.

CPT code 28505 stands for "Open treatment of fracture, great toe, phalanx or phalanges, with or without internal or external fixation." This code describes a surgical procedure that involves repairing a fracture in the bones of the great toe. This code is generally used for the surgical procedure that takes place in the outpatient setting, however, can also be used in the inpatient setting.

When and Why You Should Use CPT Code 28505

Imagine a scenario where a patient named Sarah experiences a fracture in the second phalanx of her great toe. After a thorough examination and diagnostic imaging, Sarah's orthopedic surgeon determines that the fracture is a closed fracture that requires surgical intervention.

The surgeon explains the procedure to Sarah, which includes:

Making a small incision in the skin over the fractured area to expose the toe bones

Carefully adjusting and fixing the fracture using a small metal screw for stability

Closing the incision and placing Sarah's toe in a cast to immobilize it and promote healing

In this case, CPT code 28505 would be the most appropriate code for the surgeon's procedure, since it accurately reflects the open treatment of the great toe phalanx fracture with the use of internal fixation, in this case a screw.

Common Modifiers Used with CPT Code 28505

While CPT code 28505 stands alone in capturing the core surgical procedure, modifiers play a vital role in providing additional details about the service rendered and are crucial to ensure the right amount is reimbursed for the procedure by payers. Below are common modifiers you might see used in conjunction with CPT code 28505 and how you'd use each.

Modifier 51: Multiple Procedures

Let’s say our patient, Sarah, has suffered another injury – she broke the second phalanx of her third toe, in addition to her great toe. This second procedure would be documented with CPT code 28510, which refers to the “open treatment of fracture of phalanx, middle or distal, other toe, with or without internal fixation, except great toe.” To capture this situation, a coder would append the CPT code for each toe fracture with modifier 51. Using modifier 51 would help to indicate that this procedure was performed on two or more toes on the same day, resulting in a reimbursement discount for each procedure due to the reduced time required compared to performing each procedure on a different day.

Modifier 50: Bilateral Procedure

Consider the possibility that instead of breaking her third toe, Sarah fractured the second phalanx of her other great toe, meaning the second phalanx of both of her great toes. If that happened, to communicate to the payer that this was a procedure done on both feet, a modifier 50 would be appended to the 28505 CPT code for the great toe, the modifier indicating that the procedure was performed on both sides of the body. Modifier 50 is a significant indicator as it results in a larger payment than the 51 modifier, which signals only two procedures that may be discounted.

Modifier 52: Reduced Services

The patient, Sarah, is a very petite individual. The provider found that she didn’t require full open exposure to repair her fracture due to its location and severity. The procedure was shortened and didn't require the entire procedure as described in 28505. In this scenario, the modifier 52 would be attached to the code. Modifier 52 reflects a situation where a full open procedure was not needed, and thus would mean less work was completed. This means the payment for the procedure will be reduced as well to match the amount of services delivered.

Modifier 54: Surgical Care Only

What happens when the orthopedic surgeon who treats the patient Sarah is not available to manage her postoperative recovery? They may choose to hand off the post-surgical management of her healing and care to her general practitioner. If the surgeon does not want to be financially responsible for her recovery, they might choose to append the 54 modifier to 28505 when reporting to the payer for Sarah. The surgeon would bill the full amount of their service, which in this case is only the surgical procedure.

Modifier 55: Postoperative Management Only

Following the surgical treatment, the orthopedic surgeon only wanted to provide postoperative management services. This means that the physician was not the original provider of the service that repaired Sarah's fracture, and thus, there is a specific code, modifier 55. Modifier 55 is usually reported when a practitioner only managed the postoperative care after the initial surgical repair.

Modifier 56: Preoperative Management Only

Modifier 56 is used for a scenario where the surgeon only provided the preoperative management services related to a procedure. However, as noted by AMA guidelines for CPT code 28505, the application of 56 modifier is not possible with the service as “a cast, splint, or strapping is not considered part of the preoperative care; therefore, the use of modifier 56 for preoperative management only is not applicable.” For this reason, modifier 56 would be less likely used.

Modifier 58: Staged or Related Procedure or Service by the Same Physician or Other Qualified Health Care Professional During the Postoperative Period

We know that Sarah underwent the repair to her fractured great toe, and is scheduled for a follow UP to remove the cast. This could be performed as part of the global postoperative period or as a separate visit in which Sarah is not seen for her recovery. Modifier 58 can be appended to 28505 if her provider wants to bill for the service, however, it is generally considered part of the initial surgery’s global fee for a specific period of time after the surgery and usually should not be separately billed.

Modifier 59: Distinct Procedural Service

Modifier 59 is frequently applied to 28505, and the use can often cause confusion. It’s important to recognize that the use of this modifier should only be applied if another procedure is distinct. That means the services reported with the 59 modifier must have been distinct from each other in their scope and nature. A clear example would be when Sarah has to be brought back to surgery after her initial surgical procedure because the initial surgery resulted in an unforeseen complication, requiring the need for a completely distinct and unrelated procedure. A more comprehensive evaluation of her chart would need to be conducted to determine why the 59 modifier was selected by the coder.

Modifier 76: Repeat Procedure by Same Physician or Other Qualified Health Care Professional

Modifier 76 can be applied when a service, such as the one provided by CPT code 28505, was performed again by the same physician, because the initial surgery failed or was not successful in healing the bone fracture. This procedure must be done by the same doctor as the initial repair for modifier 76 to be applicable. If Sarah went back to the same provider who initially performed the 28505 service because it did not resolve, then 28505 would be rebilled with the 76 modifier. If a new provider is doing the service, a new code must be used and documented appropriately for the patient.

Modifier 77: Repeat Procedure by Another Physician or Other Qualified Health Care Professional

While not typical for an orthopedist to perform this service again as it would usually be passed off to another specialist for additional treatment or recovery if the initial surgery is not effective, Modifier 77 is used when the procedure is being repeated, such as Sarah’s, by another physician. It is unlikely that the surgeon would repeat the same procedure because the fracture has not healed. Rather, she would be referred to a specialist like a physiatrist, who could focus on her long-term recovery needs. This would make this modifier unlikely to be appended to CPT code 28505.

Modifier 78: Unplanned Return to the Operating/Procedure Room by the Same Physician or Other Qualified Health Care Professional Following Initial Procedure for a Related Procedure During the Postoperative Period

After completing the initial procedure on Sarah, her provider may have returned her to the procedure room because an unplanned issue arose, perhaps in her wound requiring a separate procedure. An unexpected issue or complication occurring as a direct result of the 28505 code would require this modifier. This would mean there was another unrelated but associated surgical procedure that was needed for the healing. However, the modifier can only be applied if the return was during the post-operative period.

Modifier 79: Unrelated Procedure or Service by the Same Physician or Other Qualified Health Care Professional During the Postoperative Period

It is common for surgeons who are involved in their patients’ recovery to perform an unrelated procedure that may not be a result of a complication or unexpected issue stemming from the original procedure. For example, during Sarah's recovery, she discovers a new issue – a fractured bone in her arm. Modifier 79 might be applied to the new service to describe the scenario. This modifier should only be reported if the second procedure was not the result of the original procedure and the new procedure is being performed in the postoperative period.

Modifier 99: Multiple Modifiers

The final modifier, Modifier 99, indicates multiple modifiers have been applied. For example, If Sarah has been undergoing multiple services by the same provider and the service involves both a repeat and reduced service component for a 28505 procedure, modifiers 52 and 76 might be used. However, the code requires only one modifier to indicate each aspect of the service rendered. This makes modifier 99 very helpful in reducing confusion while indicating that the codes and their corresponding modifiers appropriately represent Sarah's care.

A Deeper Look at Other Modifiers That May Apply

Beyond the common modifiers highlighted, several other modifiers could be considered when coding procedures using CPT code 28505.

Modifier RT: Right Side

When Sarah returns to the surgeon for her postoperative care, they will document her status. While in the office, the provider examines her other foot for signs of healing in her great toe as part of the same visit and she discovers that she’s fractured the second phalanx in her right great toe. If her other great toe was fractured and requires surgical intervention, a different code would need to be selected depending on the treatment, but this could also require the application of modifier RT, meaning the procedure is being done on the right side of the body.

A Note on Compliance and Accuracy

It is essential for healthcare professionals and medical coders to understand that the correct application of modifiers is crucial for ensuring accurate billing and compliance with regulations. Proper coding is paramount to avoid financial penalties and ensure that healthcare providers receive appropriate reimbursements. Furthermore, failing to comply with regulations related to the use of CPT codes can result in serious legal repercussions.

A Reminder

This information provided on this site, regarding CPT code 28505, should be viewed as an educational example and should not be used as a substitute for a certified and licensed medical coder’s services. Please note, CPT codes are owned and licensed by the American Medical Association. Medical coding specialists who use these codes must purchase licenses to use the codes legally. The American Medical Association provides up-to-date codes for medical coders who utilize this system for coding and billing in various specialties. Using outdated or unlicensed codes can have severe consequences as described above and, therefore, is not recommended.

Learn about CPT code 28505 for open treatment of great toe fractures and explore common modifiers like 51, 50, 52, and 54. Discover how AI and automation can improve medical coding accuracy and efficiency. This article provides insights for medical coders and healthcare professionals.

What are the Common Modifiers Used with CPT Code 28505?