How To Use CPT Code 28715

CPT 28715 describes a specific procedure known as triple arthrodesis, which is performed on patients with degenerative arthritis or trauma. This article will cover the official description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples.

1. What is CPT Code 28715?

CPT 28715 is a code used to describe the triple arthrodesis procedure. This procedure involves fusing three joints of the ankle together – the subtalar, talonavicular, and calcaneocuboid joints. By fusing these joints, the ankle joint is completely mobilized, providing relief for patients with degenerative arthritis or trauma.

2. Official Description

The official description of CPT code 28715 is: ‘Arthrodesis; triple.’

3. Procedure

1. The provider begins by making a curved dorsolateral incision on the foot, starting from the talonavicular joint and extending to the inferior aspect of the lateral malleolus.
2. After making the incision, the provider carefully protects the dorsolateral branch of the superficial peroneal nerve and proceeds to incise the site further.
3. The provider then detaches the extensor digitorum brevis and incises the inferior retinaculum.
4. Next, the provider opens the lateral aspect of the talonavicular joint, the calcaneocuboid joint, and the posterior facet of the subtalar joint.
5. The provider removes the anterior projection of calculus and exposes the calcaneocuboid joint and sinus tarsi.
6. Articular cartilage of the calcaneocuboid and subtalar joint is removed to prepare for fusion.
7. The provider then makes a medial incision to expose the talonavicular joint, being careful to protect the saphenous vein.
8. The talonavicular joint is exposed dorsally, medially, and inferiorly, and the articular cartilage is removed.
9. Internal fixation devices such as K wires and screws are used to hold the joints together.

4. Qualifying circumstances

Triple arthrodesis is typically performed on patients with degenerative arthritis or trauma. The procedure is indicated when other conservative treatments have failed to provide relief. Patients must meet the criteria for the procedure, which is determined by the provider based on their medical history, physical examination, and diagnostic tests.

5. When to use CPT code 28715

CPT code 28715 should be used when a provider performs the triple arthrodesis procedure on a patient. It is important to ensure that the patient meets the qualifying circumstances for the procedure and that other conservative treatments have been attempted before resorting to arthrodesis.

6. Documentation requirements

To support a claim for CPT code 28715, the provider must document the following information:

• Patient’s medical history and physical examination findings
• Diagnostic tests and imaging results supporting the need for triple arthrodesis
• Details of the procedure, including the incision site, joints fused, and internal fixation devices used
• Any complications or unexpected findings during the procedure
• Post-operative care instructions and follow-up plans
• Signature of the provider performing the procedure

7. Billing guidelines

When billing for CPT code 28715, ensure that the procedure performed meets the criteria for triple arthrodesis. It is important to follow the documentation requirements and provide all necessary supporting documentation. Additionally, be aware of any specific billing guidelines or modifiers that may be required by the payer.

8. Historical information

CPT code 28715 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 degenerative arthritis undergoes triple arthrodesis to alleviate ankle pain and improve mobility.
2. An individual who experienced trauma to the ankle undergoes triple arthrodesis to stabilize the joint and promote healing.
3. A provider performs triple arthrodesis on a patient with severe ankle deformity caused by degenerative arthritis.
4. A patient with chronic ankle instability undergoes triple arthrodesis to improve joint stability and prevent recurrent sprains.
5. An individual with failed conservative treatments for ankle arthritis undergoes triple arthrodesis to relieve pain and improve function.
6. A provider performs triple arthrodesis on a patient with post-traumatic arthritis to restore joint alignment and function.
7. A patient with severe ankle pain and limited mobility due to degenerative arthritis undergoes triple arthrodesis for pain relief and improved function.
8. An individual with ankle deformity caused by trauma undergoes triple arthrodesis to correct the alignment and improve joint function.
9. A provider performs triple arthrodesis on a patient with ankle instability and recurrent sprains to stabilize the joint and prevent further injuries.
10. A patient with ankle arthritis that is unresponsive to conservative treatments undergoes triple arthrodesis to alleviate pain and improve quality of life.