How To Use CPT Code 28310

CPT 28310 describes a specific surgical procedure performed on the proximal phalanx of the first toe to correct alignment and deformity. 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 28310?

CPT 28310 is a code used to describe a surgical procedure that involves the cutting of a portion of the bone in the proximal phalanx of the first toe. This procedure is performed to correct alignment and deformity issues in the toe.

2. Official Description

The official description of CPT code 28310 is: ‘Osteotomy, shortening, angular or rotational correction; proximal phalanx, first toe (separate procedure).’ This code specifically refers to the surgical correction of alignment and deformity in the proximal phalanx of the first toe.

3. Procedure

1. During the procedure, the healthcare provider makes an incision in the skin over the proximal phalanx of the first toe.
2. They then cut through the soft tissues and incise the periosteum, which is the outer covering of the bone.
3. Next, the provider elevates the periosteum and removes a wedge-shaped piece of bone from the proximal phalanx to correct the alignment and deformity.
4. If necessary, the provider may use implants such as nails, screws, or wire to fix the bone in the correct alignment.
5. Afterward, the periosteum is reattached, and the soft tissues are sutured together to close the wound.

4. Qualifying circumstances

CPT 28310 is used when a patient requires surgical correction of alignment and deformity in the proximal phalanx of the first toe. This procedure is typically performed to address conditions such as bunions or other toe deformities. It is important to note that CPT 28310 is a separate procedure and should not be reported with related procedures performed through the same skin incision.

5. When to use CPT code 28310

CPT code 28310 should be used when a healthcare provider performs the specific surgical procedure of osteotomy, shortening, angular or rotational correction on the proximal phalanx of the first toe. It is important to ensure that this code is not reported with related procedures performed through the same skin incision. Modifier 59 may be necessary if CPT 28310 is performed with an unrelated procedure.

6. Documentation requirements

To support a claim for CPT 28310, the healthcare provider must document the following information:

• Patient’s diagnosis and the need for surgical correction
• Details of the procedure performed, including the specific bone involved and the type of correction made
• Date of the procedure
• Any additional procedures performed in conjunction with CPT 28310
• Signature of the healthcare provider performing the procedure

7. Billing guidelines

When billing for CPT 28310, it is important to ensure that the procedure is performed on the proximal phalanx of the first toe and meets the specific criteria outlined in the code description. This code should not be reported with related procedures performed through the same skin incision. Modifier 59 may be necessary if CPT 28310 is performed with an unrelated procedure.

8. Historical information

CPT 28310 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 a bunion undergoes a surgical procedure to correct the alignment and deformity in the proximal phalanx of their first toe.
2. A healthcare provider performs an osteotomy on the first toe of a patient with a severe toe deformity to improve alignment and function.
3. A patient with a misaligned first toe undergoes a surgical procedure to shorten and correct the bone in the proximal phalanx.
4. A healthcare provider performs an angular correction on the proximal phalanx of the first toe to address a toe deformity in a patient.
5. A patient with a rotational deformity in their first toe undergoes a surgical procedure to correct the alignment and improve functionality.