How To Use CPT Code 28415

CPT 28415 describes the open treatment of a calcaneal fracture, including internal fixation if performed. 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 28415?

CPT 28415 can be used to describe the open treatment of a calcaneal fracture, which involves surgical intervention to repair a fracture in the heel bone. The procedure may include the use of internal fixation, such as screws or metal plates, to stabilize the fractured fragments.

2. Official Description

The official description of CPT code 28415 is: ‘Open treatment of calcaneal fracture, includes internal fixation, when performed.’

3. Procedure

1. In this procedure, the healthcare provider performs open surgical treatment of a calcaneal fracture, also known as a heel bone fracture.
2. The patient is appropriately prepped and anesthetized.
3. The provider makes an incision in the skin over the heel bone and dissects down through the soft tissue to expose the fractured bone.
4. Nonviable or dead tissue present around the fracture site is debrided.
5. The provider aligns the fractured fragments back into their normal position.
6. If necessary, the provider may use internal fixation implants like screws or metal plates to hold the fracture fragments in their normal alignment.
7. Hemostasis is obtained at the surgical site, and the wound is closed by suturing the soft tissue in layers.

4. Qualifying circumstances

This procedure is performed on patients with a calcaneal fracture, which is a crack in the heel bone. The surgery is indicated when the fracture requires open treatment and internal fixation to ensure proper healing and alignment of the fractured fragments.

5. When to use CPT code 28415

CPT code 28415 should be used when the healthcare provider performs open treatment of a calcaneal fracture and includes internal fixation if performed. This code accurately represents the surgical procedure and the additional use of implants to stabilize the fracture.

6. Documentation requirements

To support a claim for CPT code 28415, the healthcare provider must document the following information:

• Patient’s diagnosis of a calcaneal fracture
• Details of the surgical procedure performed, including the use of internal fixation if applicable
• Date of the procedure
• Any additional findings or procedures performed during the surgery
• Signature of the healthcare provider performing the procedure

7. Billing guidelines

When billing for CPT code 28415, ensure that the procedure performed meets the criteria for open treatment of a calcaneal fracture with or without internal fixation. It is important to accurately document the use of internal fixation if applicable. Additionally, follow any specific guidelines provided by the payer regarding the reporting of this code.

8. Historical information

CPT code 28415 has undergone historical changes. It was added to the Current Procedural Terminology system on January 1, 1990. Since then, there have been updates to the code, including changes on January 1, 2008, and January 1, 2010.

9. Examples

1. A patient sustains a calcaneal fracture due to a fall and undergoes open treatment with internal fixation using screws.
2. A professional athlete fractures their heel bone during a game and requires open treatment with internal fixation to ensure proper healing and return to sports.
3. An elderly individual with osteoporosis fractures their calcaneus and undergoes open treatment with internal fixation to restore mobility and reduce pain.
4. A patient involved in a car accident sustains a severe calcaneal fracture and requires open treatment with internal fixation to prevent long-term complications.
5. A construction worker fractures their heel bone on the job and undergoes open treatment with internal fixation to facilitate a faster and more complete recovery.
6. A patient with a history of recurrent calcaneal fractures undergoes open treatment with internal fixation to address the underlying cause and prevent future fractures.
7. An individual involved in a sports-related injury fractures their calcaneus and requires open treatment with internal fixation to restore normal foot function and prevent long-term complications.
8. A patient with a complex calcaneal fracture undergoes open treatment with internal fixation to achieve proper alignment and promote optimal healing.
9. A child sustains a calcaneal fracture while playing and undergoes open treatment with internal fixation to ensure proper growth and development of the foot.
10. A patient with a calcaneal fracture that has failed to heal properly undergoes revision surgery with open treatment and internal fixation to correct the previous procedure’s outcome.