How To Use CPT Code 28119

CPT 28119 describes a surgical procedure that involves the removal of the calcaneus bone, with or without a plantar fascial release, to alleviate pain and improve range of motion. This article will provide an overview of CPT code 28119, including its official description, the procedure itself, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information, and examples.

1. What is CPT Code 28119?

CPT 28119 is a code used to describe a surgical procedure in which the provider removes the calcaneus bone, also known as the heel bone. This procedure may also involve a plantar fascial release, which is performed if necessary to relieve pain and improve the patient’s range of motion. It is important to note that CPT code 28119 should only be used when the calcaneus bone is being excised.

2. Official Description

The official description of CPT code 28119 is: ‘Ostectomy, calcaneus; for spur, with or without plantar fascial release.’ This code specifically refers to the surgical removal of the calcaneus bone, which may include a plantar fascial release if required.

3. Procedure

1. During the procedure, the provider begins by making an incision on the posterior aspect of the foot.
2. They then dissect the bursa and tendons from the insertion point of the Achilles tendon.
3. The provider separates the Achilles tendon from its attachments and identifies the exostosis, which is an abnormal bone growth on the surface of the bone.
4. They proceed to excise the spur along with the calcaneal bone.
5. The remaining calcaneus is smoothed and trimmed to remove any sharp edges.
6. If necessary, the provider may perform a plantar fascial release, which involves cutting part of the fascia to release tension and relieve inflammation on the plantar fascia.
7. Finally, the wound is closed in layers.

4. Qualifying circumstances

CPT code 28119 is typically used for patients who have a spur on the calcaneus bone that is causing pain and limited range of motion. The procedure may also involve a plantar fascial release if there is a need to relieve tension and inflammation on the plantar fascia. It is important to note that this code should only be used when the calcaneus bone is being removed.

5. When to use CPT code 28119

CPT code 28119 should be used when the provider is performing an ostectomy of the calcaneus bone, specifically for the removal of a spur. This code may also be used if a plantar fascial release is performed during the same procedure. It is important to ensure that the documentation clearly supports the need for the procedure and specifies the removal of the calcaneus bone.

6. Documentation requirements

To support a claim for CPT code 28119, the provider must document the following information:

• Patient’s diagnosis and the need for the procedure
• Details of the procedure performed, including the removal of the calcaneus bone and any additional procedures such as a plantar fascial release
• Incision site and approach used
• Any complications or unexpected findings during the procedure
• Post-operative care instructions
• Signature of the provider performing the procedure

7. Billing guidelines

When billing for CPT code 28119, it is important to ensure that the documentation supports the need for the procedure and specifies the removal of the calcaneus bone. This code should not be reported with other codes unless there are additional procedures performed during the same surgical session. It is recommended to review the specific billing guidelines provided by the payer to ensure accurate reporting and reimbursement.

8. Historical information

CPT code 28119 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 severe heel pain due to a calcaneal spur. The provider performs an ostectomy of the calcaneus bone to remove the spur and alleviate the patient’s symptoms.
2. A patient with limited range of motion in their foot due to a calcaneal spur undergoes a surgical procedure in which the provider removes the calcaneus bone and performs a plantar fascial release to improve the patient’s mobility.
3. A patient with chronic heel pain caused by a calcaneal spur undergoes a surgical procedure in which the provider excises the spur along with the calcaneus bone, providing relief and improved function.
4. A patient with a history of plantar fasciitis and a calcaneal spur undergoes a surgical procedure in which the provider removes the calcaneus bone and performs a plantar fascial release to address both conditions.
5. A patient with a painful heel spur undergoes a surgical procedure in which the provider removes the calcaneus bone, eliminating the source of the patient’s discomfort.