How To Use CPT Code 28615

CPT 28615 describes the open treatment of tarsometatarsal joint dislocation, 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 28615?

CPT 28615 is used to describe the open treatment of tarsometatarsal joint dislocation, which involves the abnormal separation of a joint. The procedure may or may not include the use of internal fixation implants, such as pins or screws, to fix the dislocation. The tarsometatarsal joint is located in the midfoot and rearfoot area and connects the tarsal and metatarsal bones.

2. Official Description

The official description of CPT code 28615 is: ‘Open treatment of tarsometatarsal joint dislocation, includes internal fixation, when performed.’

3. Procedure

1. The provider begins by making an incision in the skin over the dislocated joint.
2. She then carefully dissects through the subcutaneous tissue, taking care to protect the nerves and vessels.
3. The provider retracts the muscles to gain adequate exposure of the dislocated bones.
4. She then manipulates the bones to reduce the dislocation.
5. If necessary, the provider may use implants like screws, nails, or wires to provide additional stability to the reduced joint.
6. Finally, the provider sutures the skin layers together to close the wound.
7. A splint or brace is applied to the foot to immobilize the joint for approximately four weeks.
8. An X-ray examination may be performed separately to confirm the reduction of the dislocation.

4. Qualifying circumstances

CPT 28615 is performed on patients with tarsometatarsal joint dislocation that requires open treatment. The procedure may or may not involve the use of internal fixation implants. The provider must carefully assess the patient’s condition and determine the need for this specific treatment approach.

5. When to use CPT code 28615

CPT code 28615 should be used when the provider performs open treatment of tarsometatarsal joint dislocation, including internal fixation if performed. It is important to accurately document the procedure and ensure that it meets the criteria outlined in the code description.

6. Documentation requirements

To support a claim for CPT 28615, the provider must document the following information:

• Patient’s diagnosis of tarsometatarsal joint dislocation
• Details of the procedure performed, including whether internal fixation was used
• Date of the procedure
• Any additional procedures or services provided during the same encounter
• Signature of the provider performing the procedure

7. Billing guidelines

When billing for CPT 28615, ensure that the procedure meets the criteria outlined in the code description. It is important to accurately document the use of internal fixation if performed. Additionally, be aware of any specific payer guidelines or requirements for reporting this code. It is also important to consider any applicable modifiers that may be required for proper billing.

8. Historical information

CPT 28615 was added to the Current Procedural Terminology system on January 1, 1990. There was a code change on January 1, 2008, which expanded the description to include dislocation treatment with or without internal or external fixation.

9. Examples

1. A podiatrist performs open treatment of tarsometatarsal joint dislocation with internal fixation using screws for a patient who suffered a traumatic injury.
2. An orthopedic surgeon performs open reduction and internal fixation of tarsometatarsal joint dislocation for a patient with a chronic dislocation.
3. A foot and ankle specialist performs open treatment of tarsometatarsal joint dislocation without internal fixation for a patient with a congenital deformity.
4. A trauma surgeon performs open reduction and internal fixation of tarsometatarsal joint dislocation for a patient involved in a car accident.
5. An orthopedic surgeon performs open treatment of tarsometatarsal joint dislocation with the use of plates and screws for a patient with a severe dislocation.
6. A podiatrist performs open reduction and internal fixation of tarsometatarsal joint dislocation for a patient with a sports-related injury.
7. An orthopedic surgeon performs open treatment of tarsometatarsal joint dislocation without internal fixation for a patient with a chronic dislocation.
8. A foot and ankle specialist performs open reduction and internal fixation of tarsometatarsal joint dislocation for a patient with a traumatic injury.
9. A trauma surgeon performs open treatment of tarsometatarsal joint dislocation with the use of external fixation for a patient involved in a workplace accident.
10. An orthopedic surgeon performs open reduction and internal fixation of tarsometatarsal joint dislocation for a patient with a severe dislocation due to a fall.