How To Use CPT Code 28112

CPT 28112 describes the surgical procedure of ostectomy, which involves the complete excision of the metatarsal head, specifically the second, third, or fourth metatarsal head. This article will provide an overview of CPT code 28112, including its official description, the procedure itself, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information, and similar codes.

1. What is CPT Code 28112?

CPT 28112 is a code used to describe the surgical procedure known as ostectomy. This procedure involves the complete removal of the bone of the second, third, or fourth metatarsal head. It is typically performed when there is necrosis or infection of the metatarsal head, requiring its complete excision.

2. Official Description

The official description of CPT code 28112 is: ‘Ostectomy, complete excision; other metatarsal head (second, third or fourth).’ This code specifically refers to the surgical removal of the metatarsal head of the second, third, or fourth metatarsal bone.

3. Procedure

1. The surgeon begins by making an incision at the second, third, or fourth metatarsophalangeal joint.
2. Through this incision, the surgeon carefully dissects down through the subcutaneous tissue, ensuring the protection of nerves and vessels.
3. Once the joint capsule and any diseased synovium are exposed, the surgeon proceeds to remove them.
4. The metatarsal head is then fully exposed and completely excised.
5. To maintain the correct position, the surgeon may insert pins or wires into the metatarsal and the proximal phalanx of the toe.
6. In some cases, a cast may be applied to provide stability after the procedure.
7. The surgeon closes the incision by suturing the tissues in layers.

4. Qualifying circumstances

CPT code 28112 is used when there is a necrosis or infection of the metatarsal head, specifically the second, third, or fourth metatarsal head. The procedure is performed by a qualified surgeon and requires the complete excision of the affected metatarsal head.

5. When to use CPT code 28112

CPT code 28112 should be used when a surgeon performs a complete excision of the metatarsal head of the second, third, or fourth metatarsal bone due to necrosis or infection. It is important to accurately document the specific metatarsal head involved in the procedure.

6. Documentation requirements

To support a claim for CPT code 28112, the surgeon must document the following information:

• The diagnosis of necrosis or infection of the metatarsal head
• The specific metatarsal head (second, third, or fourth) that was excised
• Date of the procedure
• Details of the surgical technique used
• Any additional procedures performed, such as pin or wire insertion
• Post-operative care instructions
• Signature of the performing surgeon

7. Billing guidelines

When billing for CPT code 28112, ensure that the procedure performed involves the complete excision of the metatarsal head of the second, third, or fourth metatarsal bone. It is important to accurately document the specific metatarsal head involved in the procedure. Additionally, be aware of any applicable modifiers or additional codes that may be required for proper billing.

8. Historical information

CPT code 28112 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 with necrosis of the third metatarsal head undergoes a surgical procedure where the surgeon performs a complete excision of the affected metatarsal head.
2. A second metatarsal head infection necessitates a surgical procedure where the surgeon completely removes the affected bone.
3. A patient presents with an infected fourth metatarsal head, requiring a surgical procedure involving the complete excision of the affected bone.
4. A surgeon performs a complete excision of the third metatarsal head due to necrosis in a patient with a history of foot trauma.
5. A patient with an infected second metatarsal head undergoes a surgical procedure where the surgeon completely removes the affected bone.
6. A complete excision of the fourth metatarsal head is performed on a patient with necrosis caused by a chronic medical condition.
7. A surgical procedure involving the complete excision of the third metatarsal head is performed on a patient with a severe infection.
8. A patient with an infected second metatarsal head undergoes a surgical procedure where the surgeon completely removes the affected bone.
9. A complete excision of the fourth metatarsal head is performed on a patient with necrosis caused by a chronic medical condition.
10. A surgical procedure involving the complete excision of the third metatarsal head is performed on a patient with a severe infection.