How To Use CPT Code 28445

CPT 28445 describes the open treatment of a talus 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 28445?

CPT 28445 is used to describe the open treatment of a talus fracture, which involves the provider performing surgery to repair the fracture. This procedure may or may not involve the use of internal fixation implants, such as pins or screws, to stabilize the fractured bone.

2. Official Description

The official description of CPT code 28445 is: ‘Open treatment of talus fracture, includes internal fixation, when performed.’

3. Procedure

1. In this procedure, the provider begins by making an incision in the skin over the fractured talus bone.
2. They then carefully dissect through the subcutaneous tissue, taking care to protect the nerves and blood vessels.
3. The provider retracts the muscles to gain adequate exposure of the talus fracture.
4. Next, they adjust the fractured fragments of the bone to align them properly.
5. If necessary, the provider may use internal fixation implants, such as screws, nails, or wires, to stabilize the fracture and promote proper healing.
6. Finally, the provider sutures the layers of skin together to close the incision.
7. After the procedure, the patient’s ankle is typically placed in a cast or brace for a period of four to six weeks to allow for proper healing.
8. In some cases, the provider may also perform an X-ray examination of the talus to confirm the reduction of the fracture.

4. Qualifying circumstances

CPT 28445 is used for patients who have a talus fracture that requires surgical intervention. The provider must perform an open treatment of the fracture, which involves making an incision and accessing the fractured bone. The use of internal fixation implants, such as pins or screws, is optional but may be performed if necessary to stabilize the fracture.

5. When to use CPT code 28445

CPT code 28445 should be used when the provider performs an open treatment of a talus fracture, including internal fixation if performed. This code should not be used for percutaneous skeletal fixation of a talus fracture with manipulation, which is represented by a different CPT code (28436).

6. Documentation requirements

To support a claim for CPT 28445, the provider must document the following information:

• The diagnosis of a talus fracture
• A detailed description of the procedure performed, including whether internal fixation was used
• The date of the procedure
• The start and end times of the procedure
• Any additional procedures performed, such as an X-ray examination of the talus
• Any complications or unexpected findings during the procedure
• The patient’s response to the procedure and any post-operative instructions given
• The provider’s signature

7. Billing guidelines

When billing for CPT 28445, ensure that the procedure meets the criteria for an open treatment of a talus fracture, including the use of internal fixation if performed. It is important to use the appropriate CPT code based on the specific procedure performed. Additionally, be aware of any bundling or unbundling issues that may affect the billing of this code.

8. Historical information

CPT 28445 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 sustains a talus fracture and undergoes open treatment with internal fixation using screws.
2. A provider performs open treatment of a talus fracture without the use of internal fixation.
3. A patient presents with a talus fracture that requires open treatment and the use of pins for internal fixation.
4. A provider performs open treatment of a talus fracture and also performs an X-ray examination of the talus to confirm the reduction of the fracture.
5. A patient undergoes open treatment of a talus fracture with internal fixation using wires.
6. A provider performs open treatment of a talus fracture and places the patient’s ankle in a cast for four to six weeks for proper healing.
7. A patient sustains a talus fracture and undergoes open treatment with internal fixation using a combination of screws and plates.
8. A provider performs open treatment of a talus fracture and also performs a separate procedure to repair a ligament injury in the ankle.
9. A patient presents with a talus fracture that requires open treatment and the use of a nail for internal fixation.
10. A provider performs open treatment of a talus fracture and also performs a separate procedure to remove a bone spur in the foot.