In podiatry, CPT 28285 is a cornerstone code for the surgical correction of hammertoe deformities, encompassing procedures like interphalangeal fusion, partial or total phalangectomy to address painful, bent toes that impair mobility and quality of life. This minimally invasive, or open approach, is commonly performed in outpatient settings to alleviate symptoms from conditions like muscular imbalance or trauma, preventing progression to more severe foot issues. However, billing accuracy is paramount, as payers frequently deny claims due to bundling, insufficient documentation, or exceeding medically unlikely edits (MUEs). By focusing on precise operative reporting, outcome tracking, and compliance strategies, podiatrists can optimize reimbursement while enhancing patient care in 2025.

Time-based Billing

CPT 28285 is a procedure-based surgical code with a flat reimbursement rate, not inherently time-based like evaluation and management (E/M) services. Billing does not incorporate time units for the core procedure, but documenting operative time—from incision to closure—is essential for facility claims, anesthesia billing, and audit defense, typically ranging from 15-45 minutes per toe depending on complexity. Payers may require operative reports including time logs to verify the procedure's scope, especially when multiple toes are involved or add-on codes apply.

Key aspects for time-related documentation in podiatry include:

• Operative Report Essentials: Record start and end times, including setup, correction (e.g., phalangectomy), and closure; note any extensions due to complications like extensive soft tissue work.
• Anesthesia and Facility Integration: Coordinate with anesthesia records for cross-verification, as discrepancies can trigger reviews; time impacts ASC or hospital facility fees under OPPS.
• Global Period Considerations: The 90-day global surgical package includes pre- and post-op care, so avoid billing separate E/M unless unrelated and modifier -24/-25 appended; track time for unrelated visits to support claims.
• Audit Preparedness: Use electronic OR systems for precise timestamps; excessive time without justification may flag fraud concerns.

While not driving RVUs directly, accurate time tracking prevents denials by substantiating the procedure's legitimacy, particularly in multi-toe corrections where MUE limits apply.

Functional Progress Tracking for Foot Deformities

Tracking functional progress post-CPT 28285 is critical in podiatry to evaluate hammertoe correction outcomes, justify medical necessity for surgery, and monitor for complications like recurrence or adjacent deformities. Hammertoes often stem from biomechanical imbalances, so ongoing assessments help tailor rehabilitation, prevent progression, and align with quality metrics like MIPS. Tools include patient-reported outcome measures (PROMs), clinical exams, and imaging to quantify improvements in pain, gait, and toe alignment.

A structured tracking protocol includes:

• Pre- and Post-Op Assessments: Baseline and follow-up evaluations using scales like the American Orthopaedic Foot & Ankle Society (AOFAS) Lesser Toe Score or Visual Analog Scale (VAS) for pain; track range of motion and stability at 2, 6, and 12 weeks post-op.
• Radiographic Monitoring: X-rays at intervals (e.g., immediate post-op, 3 months) to assess fusion or alignment, detecting issues like non-union early.
• Functional Metrics: Gait analysis or pedobarography to measure pressure distribution; document improvements in activities like walking or shoe wear tolerance.
• Patient Education and Compliance: Track adherence to orthotics or physical therapy, noting barriers in rural or elderly patients to adjust plans.
• Long-Term Follow-Up: Annual checks for deformity recurrence, integrating with chronic care for underlying issues like diabetes.

Digital tools like EHR-integrated PROMs streamline tracking, supporting appeals by demonstrating surgical efficacy and necessity.

Denial Prevention

Denials for CPT 28285 are prevalent in podiatry, often due to bundling, MUE violations (limit of 4 units per session), lack of medical necessity, or modifier errors, with rates exacerbated by sloppy documentation. Payers like Medicare require proof of failed conservative treatment (e.g., 3 months of orthotics or taping) and specific ICD-10 codes such as M20.41 (hammertoe).

Strategies to mitigate include:

• Modifier Usage: Append -59 or toe-specific T modifiers (e.g., -T6 for second digit) for distinct procedures; avoid unbundling with included services like tenotomy.
• Medical Necessity Documentation: Detail persistent pain, functional impairment, and conservative failures in notes; link to diagnoses like Q66.89 (congenital foot deformity).
• Bundling Checks: Review NCCI edits pre-submission; 28285 bundles with lesser toe procedures on the same digit but allows separate billing for different toes up to MUE.
• Pre-Submission Verification: Use eligibility tools for prior authorization if required; audit claims for complete operative reports.
• Appeal Processes: For denials, submit redeterminations with enhanced records, referencing guidelines like Aetna's policy on persistent symptoms.

Implementing coding software and staff training can further reduce errors, ensuring smooth revenue cycles. By integrating these best practices for CPT 28285, podiatry providers can improve surgical outcomes, minimize financial losses, and focus on patient-centered care for foot deformities.