One of the most performed surgeries in orthopedics is bunion surgery. The surgery itself is simple. However, its billing is not. Many billers use the wrong code or use the correct code in an incorrect manner. This means more claim denials and revenue loss for healthcare providers.
CPT code 28296 is used frequently to report such surgeries. That’s why our experts at NeuraBill have created this guide. We will explain what code 28296 is and how you can use it effectively in your claims. So, let’s start.
CPT Code 28296 – Description
CPT code 28296 is defined as:
“Correction, hallux valgus with bunionectomy, with sesamoidectomy when performed; with distal metatarsal osteotomy, any method.”
Code 28296 is an orthopedic surgical code. It is used to correct the hallux valgus, which is a deformity of the foot. In hallux valgus, the big toe deviates laterally toward the second toe, creating a bony prominence at the base of the first metatarsophalangeal joint. This prominence is called the bunion.
Now that we have explained the basics, let’s simplify the complex terms in the definition and understand the requirements that must be met for this code to be valid:
- Bunionectomy: Bunionectomy, which involves resection of the medial aspect of the head of the first metatarsal, must be performed for this code to apply.
- Sesamoidectomy: 28296 includes the removal of one or both sesamoid bones if they are fractured, inflamed, or otherwise contributing to the patient’s symptoms. What’s important to note is the phrase “when performed”. It means that sesamoidectomy is not mandatory for this code to be applicable.
- Distal Metatarsal Osteotomy, Any Method: This refers to the surgical cutting of the metatarsal bone closer to the toe. There is no restriction on the method used. The physician can use any method for this part that they think is best.
Appropriate Use Cases for CPT Code 28296
To better understand CPT code 28296 and its practical usage, let’s look at a couple of real-world scenarios where it applies.
Failed Conservative Management
Suppose a patient comes to an orthopedic surgeon. He complains of having persistent pain at the base of the right big toe. The patient shares that the pain and discomfort have worsened over the past two years, and over-the-counter painkillers are no good. Also, prior treatment included custom orthotics, wider footwear, and a course of anti-inflammatory medications, none of which provided lasting relief. Upon physical examination and weight-bearing radiographs, the physician confirms hallux valgus deformity.
Given the documented failure of conservative measures, the physician recommends surgical correction. The surgeon performs a bunionectomy and realigns the distal metatarsal (osteotomy). In this case, the billing department can use CPT code 28296 with modifier RT to bill the procedure.
Hallux Valgus with Sesamoid Involvement
For this example, suppose a patient visits an orthopedic clinic. He has chronic pain at the first metatarsophalangeal joint. He also has imaging results for which he got advice from another physician. The results confirm hallux valgus. So, after 6 months of failed conservative treatment, surgery is needed to treat the condition. During the preoperative workup, imaging also reveals that one of the sesamoid bones is inflamed and contributing to the patient’s discomfort.
The surgeon performs a bunionectomy with a distal metatarsal osteotomy and also removes the affected sesamoid bone during the same procedure. The billing department can submit the claim with CPT code 28296.
Modifiers to Append with CPT Code 28296
The following modifiers are frequently used with CPT code 28296:
| Modifier | Short Description | Usage |
|---|---|---|
| RT | Right Side | Use when the bunionectomy is performed on the right foot. |
| LT | Left Side | Use when the bunionectomy is performed on the left foot. |
| 22 | Increased Procedural Services | Use when the procedure involves substantially greater complexity or time than usual. |
| 50 | Bilateral Procedure | Use when the procedure is performed on both feet during the same surgical session. |
| 51 | Multiple Procedures | Append to the secondary procedure when CPT 28296 is performed alongside another distinct procedure in the same session. |
| 54 | Intraoperative Percentage | Applied when only intraoperative services are performed. |
| 55 | Postoperative Percentage | Modifier 55 is used when seeking reimbursement for only postoperative services. |
| 56 | Preoperative Percentage | This modifier is applied when billing for preoperative services. |
| 62 | Co-surgeons, Different Speciality Surgeons | Used when two surgeons of different specialties work together as primary surgeons. |
| 80, 81, 82 | Assistant Surgeon | Indicates that another physician assisted during the procedure. |
Reimbursement Guidelines for CPT Code 28296
The following are some essential billing guidelines that you must know before filing claims for CPT code 28296:
Understand the Reporting Rules
CPT code 28296 cannot be billed alongside CPT 28297 or CPT 28299 for the same foot during the same session because these codes represent incremental (step-up) procedures for the same surgical correction, i.e., hallux valgus (bunion) correction, and performing them together would be anatomically redundant and clinically inappropriate. So, to avoid double-dipping, do not report these codes together.
Provide Comprehensive Documentation
Documentation is key for any insurance claim, and CPT code 28296 claims aren’t any different. Without proper documentation, your claims will be rejected. For CPT code 28296, your operative report and supporting medical records must include:
- A confirmed diagnosis of hallux valgus.
- Imaging results that support the diagnosis.
- Documented failure of conservative treatments such as orthotics, physical therapy, anti-inflammatory medications, or footwear modifications.
- A clear description of the specific osteotomy technique performed
- Confirmation of whether a sesamoidectomy was performed and the clinical reasoning behind it.
- Details of any fixation hardware used, including type and size.
- Postoperative instructions, weight-bearing status, and follow-up plan.
Apply the Correct ICD-10 Codes
Always document the clinical indication by reporting the most precise diagnosis codes on the claim form. The most commonly used ICD-10 codes for this procedure are:
- M20.10: Hallux valgus (acquired), unspecified foot.
- M20.11: Hallux valgus (acquired), right foot.
- M20.12: Hallux valgus (acquired), left foot.
Verify the Medicare Reimbursement Rate
The reimbursement rate for CPT code 28296 varies for each payer and Medicare Administrative Contractor (MAC). However, Medicare’s national average reimbursement rate for 28296 in facility settings is $484.31 and $883.45 in non-facility settings.
You can check the exact amount for your MAC locality via the PFS Lookup Tool. Here’s how the reimbursement is divided among the three components:
- Pre-OP: 0.10 (10% of the total payment)
- Intra-OP: 0.69 (69% of total payment)
- Post-OP: 0.21 (21% of the total payment)
Final Thoughts on CPT Code 28296
Let’s wrap up everything we have discussed.
- CPT code 28296 is an orthopedic billing code used to bill a hallux valgus correction with bunionectomy and distal metatarsal osteotomy.
- For proper reimbursement, you must append the appropriate laterality modifiers to the CPT code and provide detailed documentation.
- The code has a 90-day global period, so preoperative, intraoperative, and postoperative care are included in the reimbursement amount.
However, bunion surgery claims can face complexities that go beyond basic coding rules, from NCCI edit conflicts to MAC-specific coverage policies. If your practice is experiencing denials or wants to strengthen its revenue cycle operations, consider working with professionals who offer specialized orthopedic billing services, like NeuraBill.
