Open Mouth, Insert Foot: Partial Foot and Toe Amputations

March 1st, 2013

Knowing anatomy and procedure differences will clarify coding and save you from embarrassing misconception.

By Maryann C. Palmeter, CPC, CENTC

I recall reviewing some documentation where a patient had a foot amputated, and about two months later the same patient underwent an amputation of the same foot. I thought, “How many times can the same foot be amputated? There’s something wrong here.”

It’s Not All or Nothing

I am glad I didn’t say out loud what I was thinking, or I would have ended up with a foot in my mouth, so to speak. As it turns out, my perception of foot amputations was wrong. Not every operation labeled a foot amputation results in the removal of the entire foot; therefore, it is indeed possible for a patient to have multiple amputations at more proximal levels, if a disease progresses.

A partial foot amputation (PFA) may occur in patients with advanced vascular disease secondary to diabetes and its complications, but also may occur due to injury, infection, or birth defect. Numerous complications—including skin breakdown, non-healing ulceration, osteomyelitis, and/or gangrene—can lead to a subsequent and more proximal amputation.

The goal of amputation is successful healing, preserving as much function as possible, and creating a residual limb that will work best with or without a prosthesis. Other issues that affect decisions about the type and extent of surgery include the patient’s overall health and his or her ability to withstand anesthesia, the level at which there is adequate blood flow, the potential for successful rehabilitation, and the desired activity level afterward.

Review Your Anatomy and Terminology

An understanding of the skeletal anatomy of the ankle, foot, and toes is key in amputations because CPT® code selection is based primarily on the joint(s) through which the disarticulation occurs. See Figure A for a labeled diagram of its anatomy.

Assigning codes will be easier, too, if you are familiar with various types of ankle, foot, and toe amputations. Types of amputations are:

Boyd – Similar to Syme amputation (below), but provides a broad weight-bearing surface of the heel by creating an arthrodesis between the distal tibia and the tuber of the calcaneus. This provides more length and better preserves the weight-bearing function of the heel pad than the Syme. The Boyd amputation preserves the calcaneus, and the calcaneus is fused to the tibia. This relieves the problem of migration of the heel pad because the heel pad remains firmly attached to the calcaneus. Both malleoli are preserved.

Chopart – Midtarsal amputation of the foot between the calcaneus and the cuboid bones (Calcaneocuboid joint) and the talus and the navicular bones (Talocalcaneonavicular joint).

Hey – Amputation of the foot between the metatarsus and tarsus or tarsometatarsal joint, which is located between the base of the first through fifth metatarsal bones and their connection with the medial, intermediate, and lateral cuneiforms and the cuboid bone in the foot.

Lisfranc – Same as the Hey amputation.

Pirogoff – Amputation of the foot at the ankle wherein the anterior two thirds of the calcaneus is removed, and the posterior process of the calcaneum is retained at the skin flap and opposed to the cut end of the tibia. Both malleoli are preserved.

Ray – Amputation of the toe along with all or part of the corresponding metatarsal bone.

Syme – Disarticulation of the foot with removal of both malleoli, followed by forward rotation of the heel pad over the end of the residual tibia. This technique provides an end-bearing stump that allows ambulation over short distances. The residual limb ends at the distal base of the tibia. A complication of the Syme amputation is migration of the heel pad, which is not firmly fixed to the tibia.

Terminal Syme – Amputation of part of the distal phalanx, which is performed via an elliptical incision and involves resection of the toenail, nail bed, and approximately half of the distal phalanx. The wound is closed by placing the skin flap over the stump and suturing the skin. Although the skin flap technique is similar to the one used in the Syme amputation of the ankle, do not confuse these two very distinct procedures.

Transmetatarsal – Amputation of all toes at the metatarsals.

The CPT® codes to report ankle, foot, and toe amputations are:

27888   Amputation, ankle, through malleoli of tibia and fibula (eg, Syme, Pirogoff type procedures), with plastic closure and resection of nerves

(Use this code for Boyd amputation, as well.)

27889   Ankle disarticulation

28800   Amputation, foot; midtarsal (eg, Chopart type procedure)

(Use this code for Hey and Lisfranc amputations, as well.)

28805   Amputation, foot; transmetatarsal

28810   Amputation, metatarsal, with toe, single

(Use this code for a ray amputation.)

28820   Amputation, toe; metatarsophalangeal joint

(Use this code for amputation between the metatarsal joint and proximal phalanx.)

28825   Amputation, toe; interphalangeal joint

Use this code for amputation between proximal and middle phalanges or middle and distal phalanges in toes two through five, or amputation between the distal and proximal phalanges in the big toe.

11752   Excision of nail and nail matrix, partial or complete (eg, ingrown or deformed nail), for permanent removal; with amputation of tuft of distal phalanx

Use this code to report amputation of distal tuft of phalanges or terminal Syme amputation of the toe.

Don’t forget to use modifiers to denote laterality (modifier LT Left side and RT Right side), and to distinguish one toe from another.

Toe Modifiers

Left Foot Digit

Modifier

Right Foot Digit

Modifier

Great (big) toe – This little piggy went to market. TA Great (big) toe T5
Second – This little piggy stayed home. T1 Second T6
Third – This little piggy had roast beef. T2 Third T7
Fourth – This little piggy had none. T3 Fourth T8
Fifth (pinky toe) – This little piggy went wee, wee, wee all the way home. T4 Fifth (pinky toe) T9

 

Examples Show the Coding Way

Scenario: A diabetic patient suffers from gangrene in the fourth and fifth toes of the right foot. The physician performs a ray amputation of these toes and documents that if the ray amputation does not halt the progression of the gangrene, a more aggressive course of treatment may need to be taken. Three weeks later, the gangrene has progressed at a rapid pace and the same physician performs a Chopart amputation of the right foot. The physician documents the previous procedure as unsuccessful at stopping the progression of the tissue death, and a more extensive procedure was warranted. A temporary closure was made and the operative note states the plan is to perform a secondary closure the following week. The patient was returned to the operating room five days later, and an extensive secondary closure was performed. The physician documents that the secondary closure was planned prospectively at the time of the Chopart amputation.

Initial Surgery

28810-T8 (ray amputation with application of modifier for forth digit on the right foot)

28810-51-T9 (ray amputation with application of Multiple procedures modifier, and modifier for fifth digit on the right foot)

Second Surgery

28800-58-RT (Chopart amputation with application of modifier for Staged or related procedure or service by same physician during the postoperative period of the initial surgery followed by RT modifier to designate right side of the body)

Because the Chopart amputation was performed during the post-operative period of the ray amputations and it was a more extensive procedure, append modifier 58 to the Chopart amputation procedure code. Also, the documentation mentioned that a more extensive course of treatment may need to be followed if the ray amputations were not successful in mitigating the necrosis.

Third Surgery

13160-58-RT (Secondary closure of surgical wound or dehiscence, extensive or complicated)

Because the secondary wound closure was planned prospectively at the time of the Chopart amputation, and it was performed within the post-operative period of the Chopart amputation (remember a new post-operative period began with the Chopart procedure), append modifier 58 to this procedure code. Modifier RT was appended to reflect that the procedure was performed on the right side of the body.

When appending multiple modifiers, append the modifier that impacts payment first. In this case, modifier 58 affects payment because it triggers the start of a new global period.

Let My Experience Be a Lesson

The next time you come across something in an operative or procedure note that appears a bit unusual, do a little more research before you end up with a foot in your mouth.

Maryann C. Palmeter, CPC, CENTC, has over 29 years of experience in the health care industry, with emphasis on federal and state government payer billing and compliance regulations. She has gained extensive experience through her work on both the billing and government contractor ends of the health care industry spectrum. Ms. Palmeter is employed with the University of Florida Jacksonville Healthcare, Inc. as the director of physician billing compliance for the University of Florida College of Medicine – Jacksonville. She is a member of the AAPC National Advisory Board (NAB) and was named 2010 Member of the Year.

Credits: The author would like to acknowledge Stephen Meritt, DPM, and Joseph Sindone, DPM, with the University of Florida College of Medicine – Jacksonville Department of Orthopaedics and Rehabilitation, for sharing their clinical insight. Thanks also to Smart Feet Savannah: www.smartfeetsavannah.com/smart-reference-library/where-does-it-hurt/foot-types/amputations.

 


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