How To Use CPT Code 28102

CPT 28102 describes the excision or curettage of a bone cyst or benign tumor in the talus or calcaneus, along with the use of an autograft for repair. This article will cover the description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples.

1. What is CPT Code 28102?

CPT 28102 is used to describe the surgical procedure in which a bone cyst or benign tumor in the talus or calcaneus is removed. The provider also harvests an autograft, which is tissue taken from the patient’s own body, to repair the site. This code is used when the excision or curettage procedure is performed along with the use of an autograft.

2. Official Description

The official description of CPT code 28102 is: ‘Excision or curettage of bone cyst or benign tumor, talus or calcaneus; with iliac or other autograft (includes obtaining graft).’ This code specifically refers to the excision or curettage procedure performed on a bone cyst or benign tumor in the talus or calcaneus, along with the use of an autograft for repair. It also includes the process of obtaining the graft.

3. Procedure

1. The provider begins by making an incision in the skin over the cyst or tumor in the ankle or heel.
2. They then carefully dissect through the subcutaneous tissue, ensuring the protection of nerves and vessels.
3. The provider identifies the bone cyst or benign tumor in the talus or calcaneus.
4. Using a curette, they scrape or excise the lesion from the bone.
5. The provider harvests an autograft, typically from the iliac bone.
6. The autograft is then secured to the site where the tumor or bone cyst was removed.
7. The wound is irrigated with an antibiotic solution and closed in layers.

4. Qualifying circumstances

CPT 28102 is performed on patients who have a bone cyst or benign tumor in the talus or calcaneus that requires excision or curettage. The use of an autograft for repair is also a qualifying circumstance for this code. The procedure must be performed by a qualified healthcare professional and meet the specific criteria outlined in the code description.

5. When to use CPT code 28102

CPT code 28102 should be used when a bone cyst or benign tumor in the talus or calcaneus is excised or curetted, and an autograft is used for repair. This code should not be used if an allograft (tissue from a donor) is used instead of an autograft. It is important to accurately document the procedure and ensure that it meets the criteria outlined in the code description.

6. Documentation requirements

To support a claim for CPT 28102, the healthcare professional must document the following information:

• Patient’s diagnosis of a bone cyst or benign tumor in the talus or calcaneus
• Details of the excision or curettage procedure
• Use of an autograft for repair
• Specific location of the cyst or tumor
• Procedure start and end times
• Any additional procedures performed during the same session
• Any complications or unexpected findings
• Signature of the healthcare professional performing the procedure

7. Billing guidelines

When billing for CPT 28102, ensure that the procedure meets the criteria outlined in the code description. Use the appropriate code based on the use of an autograft for repair. It is important to accurately document the procedure and any additional services provided during the same session. Be aware of any specific billing guidelines or modifiers that may apply to this code.

8. Historical information

CPT 28102 was added to the Current Procedural Terminology system on January 1, 1990. There have been no updates or changes to the code since its addition.

9. Examples

1. A patient undergoes excision of a bone cyst in the talus, and an autograft is used for repair.
2. A provider performs curettage of a benign tumor in the calcaneus, and an autograft is used for repair.
3. An individual requires excision of a bone cyst in the talus, and an autograft from the iliac bone is used for repair.
4. A patient undergoes curettage of a benign tumor in the calcaneus, and an autograft from another bone is used for repair.
5. A provider performs excision of a bone cyst in the talus, and an autograft is obtained from a different site for repair.