Appeal type: Surgery
Decision: Partially Favorable

We decided that the Plan has to pay for CPT codes 28005 and 11044. We decided that the Plan does not have to pay for CPT code 28420.
You asked the Plan to pay for CPT codes 28005, 11044 and 28420. You say that the medical records support the billing of these codes. The Plan says that the medical records do not support the billing of these codes.
We decided that the Plan has to pay for CPT codes 28005 and 11044.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 28005 is Incision, bone cortex (eg, osteomyelitis or bone abscess), foot, and the definition of code 11044 is Debridement, bone (includes epidermis, dermis, subcutaneous tissue, muscle and/or fascia, if performed); first 20 sq cm or less. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request for payment of CPT codes 28005 and 11044. Our reviewer says that the medical records support the billing of CPT codes 28005 and 11044. Our physician reviewer found that the medical records do support the billing of CPT code 28005 - incision, bone cortex, for osteomyelitis or bone abscess. The operative note advises that multiple holes were created in the calcaneus down to the medullary canal in order to remove any nonviable bone and insert antibiotic and bone cement. It was noted that nonviable bone was removed. Also, the medical records do support the billing of CPT code 11044 - debridement, bone, first 20 cm or less. The operative note advises that a partial calcanectomy was performed, and calcaneal fragments were removed from the calcaneus. We looked at the physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of payment for CPT codes 28005 and 11044 have been met. Therefore, we decided that the Plan has to pay for CPT codes 28005 and 11044.
We also decided that the Plan does not have to pay for CPT code 28420.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 28420 is Open treatment of calcaneal fracture, includes internal fixation, when performed; with primary iliac or other autogenous bone graft (includes obtaining graft). We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request for payment of CPT code 28420. Our reviewer says that the medical records do not support the billing of CPT code 28420. Our physician reviewer found that the medical records do not support the billing of 28420-Open treatment of calcaneal fracture, includes internal fixation, when performed; with primary iliac or other autogenous bone graft (includes obtaining graft). The enclosed operative note states "attention was directed to the fracture calcaneus which was percutaneously reduced and stabilized. Reduction stabilization was checked under fluoroscopy and noted to be adequate." Code 28420 specifically states that the procedure performed is "open treatment of calcaneal fracture." The operative note states that fracture was reduced and stabilized percutaneously. We looked at the physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of payment for CPT code 28420 have not been met. Therefore, we decided that the Plan does not have to pay for CPT code 28420.