How To Use CPT Code 28113

CPT 28113 describes the complete excision of the fifth 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 28113?

CPT 28113 is used to describe the surgical removal of the bone of the fifth metatarsal head. This procedure is performed when there is necrosis or infection of the metatarsal head, and it involves the complete excision of the bone.

2. Official Description

The official description of CPT code 28113 is: ‘Ostectomy, complete excision; fifth metatarsal head.’

3. Procedure

1. The provider begins by making an incision at the fifth 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 metatarsal head and completely removes it.
5. Pins or wires may be inserted into the metatarsal and the proximal phalanx of the toe to maintain proper positioning.
6. A cast may be applied for stability after closing the wound.
7. The provider closes the wound by suturing the tissues in layers.

4. Qualifying circumstances

CPT 28113 is performed when there is necrosis or infection of the fifth metatarsal head. It is important to note that this code specifically applies to the complete excision of the fifth metatarsal head. Other codes should be used for the removal of the first, second, third, or fourth metatarsal head.

5. When to use CPT code 28113

CPT code 28113 should be used when the provider performs a complete excision of the fifth metatarsal head. It is important to accurately document the specific bone being excised to ensure proper coding and billing.

6. Documentation requirements

To support a claim for CPT 28113, the provider must document the following information:

• Patient’s diagnosis indicating the need for the excision
• Specific bone being excised (fifth metatarsal head)
• Date of the procedure
• Details of the surgical technique used
• Any additional procedures performed, such as the insertion of pins or wires
• Post-operative care instructions
• Signature of the provider

7. Billing guidelines

When billing for CPT 28113, ensure that the procedure involves the complete excision of the fifth metatarsal head. It is important to accurately document the specific bone being excised to avoid any coding errors. Additionally, be aware of any applicable modifiers or bundling guidelines that may affect the billing of this code.

8. Historical information

CPT 28113 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 a complete excision of the fifth metatarsal head due to necrosis.
2. A provider performs the surgical removal of the fifth metatarsal head to treat an infection.
3. During the procedure, the fifth metatarsal head is completely excised to address a bone-related condition.
4. A patient with a diseased fifth metatarsal head undergoes a complete excision to alleviate symptoms.
5. The provider performs the surgical removal of the fifth metatarsal head to improve the patient’s overall foot health.
6. A complete excision of the fifth metatarsal head is performed to address a chronic condition in the foot.
7. A patient undergoes the surgical removal of the fifth metatarsal head to prevent further complications.
8. The provider performs a complete excision of the fifth metatarsal head to promote healing and recovery.
9. A patient with a severely damaged fifth metatarsal head undergoes a complete excision to restore foot function.
10. The surgical removal of the fifth metatarsal head is performed to address a congenital abnormality in the foot.