How To Use CPT Code 28232

CPT 28232 describes a specific procedure known as tenotomy, which involves the surgical division of a single flexor tendon in the toe. This article will cover the official description, procedure details, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples.

1. What is CPT Code 28232?

CPT 28232 is a code used to describe a surgical procedure called tenotomy. This procedure involves the cutting or division of a single flexor tendon in the toe using an open incision. It is typically performed as part of a more extensive procedure to correct deformities caused by muscle shortening, such as mallet toe.

2. Official Description

The official description of CPT code 28232 is: ‘Tenotomy, open, tendon flexor; toe, single tendon (separate procedure).’ This code specifically refers to the surgical division of a single flexor tendon in the toe using an open incision. It is important to note that this code is for the toe, not the foot, and it is performed as a separate procedure.

3. Procedure

1. During the procedure, the patient is typically under local, regional, or general anesthesia.
2. The orthopedic surgeon makes an incision over the shortened flexor tendon on the bottom of the toe.
3. The surgeon identifies the specific flexor tendon that needs to be divided.
4. A scalpel is inserted into the affected tendon, and the surgeon rotates it to reduce tension.
5. In the case of mallet toe, the surgeon performs flexor tenotomy at the plantar aspect of the proximal interphalangeal (PIP) joint.
6. The surgeon then stretches the toe to the desired position and length before closing the incision and applying a sterile dressing.
7. Pre-operative surgical evaluation and post-surgical management are the responsibilities of the orthopedic surgeon.

4. Qualifying circumstances

CPT 28232 is typically performed to correct deformities caused by congenital or acquired muscle shortening. It is commonly used to address mallet toe, which is a deformity characterized by a curling of the distal interphalangeal joint of a lesser toe. The procedure involves the division of a single flexor tendon in the toe through an open incision. It is important to note that this code is specific to the toe and not the foot.

5. When to use CPT code 28232

CPT code 28232 should be used when a surgeon performs a tenotomy procedure on a single flexor tendon in the toe using an open incision. It is important to ensure that the procedure is performed as a separate procedure and not as part of another surgical intervention. This code should not be used for tenotomy procedures on the foot or when a percutaneous approach is used.

6. Documentation requirements

To support a claim for CPT code 28232, the following documentation is typically required:

• Documentation of the patient’s diagnosis and the need for the tenotomy procedure
• Details of the specific flexor tendon that was divided
• Date of the procedure
• Details of the surgical technique used, including the incision site and any additional procedures performed
• Documentation of the desired position and length of the toe after the procedure
• Pre-operative surgical evaluation and post-surgical management notes

7. Billing guidelines

When billing for CPT code 28232, it is important to ensure that the procedure meets the specific criteria outlined in the code description. This includes performing a tenotomy on a single flexor tendon in the toe using an open incision. It is also important to follow payer instructions regarding the documentation of multiple units and the use of modifiers, such as 59 or TA-T9 modifiers, if applicable.

8. Historical information

CPT code 28232 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. An orthopedic surgeon performs a tenotomy procedure on a patient with mallet toe, dividing the flexor tendon in the affected toe through an open incision.
2. A patient undergoes a tenotomy procedure on their second toe to correct a deformity caused by muscle shortening, with the surgeon using an open incision to divide the flexor tendon.
3. An orthopedic surgeon performs a tenotomy procedure on a patient’s fifth toe, using an open incision to divide the flexor tendon and correct a deformity.
4. A patient with a congenital toe deformity undergoes a tenotomy procedure, with the surgeon using an open incision to divide the flexor tendon and improve the alignment of the toe.
5. An orthopedic surgeon performs a tenotomy procedure on a patient’s third toe, using an open incision to divide the flexor tendon and address a muscle shortening deformity.
6. A patient with mallet toe undergoes a tenotomy procedure, with the surgeon using an open incision to divide the flexor tendon and correct the curling of the toe.
7. An orthopedic surgeon performs a tenotomy procedure on a patient’s fourth toe, using an open incision to divide the flexor tendon and improve the alignment of the toe.
8. A patient with a acquired toe deformity undergoes a tenotomy procedure, with the surgeon using an open incision to divide the flexor tendon and correct the muscle shortening.
9. An orthopedic surgeon performs a tenotomy procedure on a patient’s big toe, using an open incision to divide the flexor tendon and address a congenital deformity.