03/13/2024    Michael G. Warshaw, DPM, CPC

Denial of Flexor Tenotomies (Vince Marino, DPM)

More often than not, it appears that it is the
Medicare Advantage Plans that always find a way to
not reimburse for a claim that was submitted. In
the posted scenario, two flexor tenotomies were
performed and billed for using CPT code 28230
appended by the toe modifiers. The payer denied
charges stating" denied for exceeds
number/frequency approved/allowed. Unfortunately,
in this instance the issue is not the Medicare
Advantage Plan, but rather the incorrect way that
this procedure code set was billed.

CPT code 28230 is defined as the following:
Tenotomy, open, tendon flexor; foot single or
multiple tendon(s) (separate procedure). Clearly,
this CPT code is not intended to be used to
indicate that a flexor tenotomy was performed on a
toe. The definition of the CPT code demonstrates
that the flexor tenotomy is performed within the
foot, not the toe and the CPT code is billed if one
or more flexor tendons are addressed. It is
apparent that this CPT code can only be billed one
time per date of service. Billing the CPT code on
two lines and appending a toe modifier on both
lines was incorrect. Therefore, the response by
Blue Cross Medicare Advantage PPO was correct when
it stated that " denied for exceeds
number/frequency approved/allowed.``

In order to bill appropriately there are two
options. If an open flexor tenotomy was performed,
the correct CPT code to bill is 28232 which is
defined as the following: Tenotomy, open, tendon
flexor; toe, single tendon (separate procedure).
The coding scenario would be the following:
28232 - T8
28232 - T5

If a percutaneous flexor tenotomy was performed,
the correct CPT code to bill is 28010 which is
defined as the following: Tenotomy, percutaneous,
toe single tendon. The coding scenario would be the
following:
28010 - T8
28010 - T5

Michael G. Warshaw, DPM, CPC, Mount Dora, FL

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