How To Use CPT Code 28111

CPT 28111 describes the complete excision of the first metatarsal head, a surgical procedure performed when there is necrosis or infection of the metatarsal head. 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 28111?

CPT 28111 is used to describe the complete excision of the bone of the first metatarsal head. This procedure is typically performed when there is necrosis or infection of the metatarsal head, requiring its complete removal. The provider surgically removes the bone to alleviate the condition and promote healing.

2. Official Description

The official description of CPT code 28111 is: ‘Ostectomy, complete excision; first metatarsal head.’

3. Procedure

1. The provider begins by making an incision at the first metatarsophalangeal joint.
2. They then carefully dissect through the subcutaneous tissue, ensuring the protection of nerves and vessels.
3. The joint capsule and any diseased synovium are removed.
4. The provider exposes the first metatarsal head and completely removes it.
5. Pins or wires may be inserted into the first metatarsal and the proximal phalanx of the big toe to maintain proper positioning.
6. A cast may be applied for stability.
7. Finally, the wound is closed in layers.

4. Qualifying circumstances

CPT 28111 is performed when there is necrosis or infection of the first metatarsal head. This condition may cause significant pain and discomfort, impairing the patient’s ability to walk or engage in daily activities. The procedure is typically performed by a qualified healthcare professional who has the necessary expertise in foot and toe surgeries.

5. When to use CPT code 28111

CPT code 28111 should be used when the provider performs a complete excision of the first metatarsal head due to necrosis or infection. It is important to accurately document the medical necessity for this procedure and ensure that it is the appropriate treatment option for the patient’s condition.

6. Documentation requirements

To support a claim for CPT 28111, the healthcare professional must document the following information:

• The patient’s diagnosis, indicating the presence of necrosis or infection in the first metatarsal head
• A detailed description of the procedure performed, including the incision, dissection, removal of the joint capsule and synovium, complete excision of the metatarsal head, and any additional steps taken
• The date of the procedure
• The start and end time of the procedure
• Any complications or unexpected findings during the procedure
• Post-operative care instructions, including the use of pins, wires, or a cast
• The provider’s signature

7. Billing guidelines

When billing for CPT 28111, ensure that the procedure performed meets the criteria for complete excision of the first metatarsal head. It is important to accurately code and document the procedure to support medical necessity and appropriate reimbursement. CPT code 28111 should not be reported with other codes unless there are specific circumstances that warrant additional coding. It is recommended to review the official coding guidelines and consult with a coding specialist for specific billing questions or concerns.

8. Historical information

CPT code 28111 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 presents with necrosis of the first metatarsal head, causing severe pain and limited mobility. The provider performs a complete excision of the metatarsal head (CPT 28111) to alleviate the condition and promote healing.
2. An individual develops an infection in the first metatarsal head, leading to significant discomfort and difficulty walking. The healthcare professional performs a complete excision of the metatarsal head (CPT 28111) to remove the infected tissue and restore proper foot function.
3. A patient experiences necrosis of the first metatarsal head due to an underlying medical condition. The provider performs a complete excision of the metatarsal head (CPT 28111) to address the necrotic tissue and improve the patient’s quality of life.
4. An individual sustains a traumatic injury to the first metatarsal head, resulting in severe damage and impaired foot function. The healthcare professional performs a complete excision of the metatarsal head (CPT 28111) to remove the damaged tissue and facilitate healing.
5. A patient develops a chronic infection in the first metatarsal head, causing persistent pain and limited mobility. The provider performs a complete excision of the metatarsal head (CPT 28111) to eliminate the source of infection and improve the patient’s overall foot health.