05/24/2024    Keith Gurnick, DPM

Coding for Haglund’s Deformity (Pamela Abshire, CPC)

The late great Harry Goldsmith, DPM, founder of
Codingline discussed this issue as follows:

A Haglund's deformity is a prominence of
bone located at the posterior-superior aspect of
the calcaneus. It may be associated
with "prominence of a bursal projection"
(retrocalcaneal bursitis), posterior calcaneal
spur, and/or Achilles tendinitis. The proper CPT
code for correcting a Haglund's deformity depends
on what specifically was performed, what was
independent, and what was a component.

Excision of a Haglund's deformity may be
coded either as CPT 28118 - ostectomy, calcaneus
(ostectomy being the surgical removal of bone) -
RVU 13.99 facility or

CPT 28120 - partial excision - craterization,
saucerization - calcaneal bone for bossing
(bossing being a circular or knoblike
protuberance of bone) - RVU 15.92 facility
You may ask, "What is the difference
between CPT 28118 and CPT 28120?" And the most
likely answer is "1.93 RVUs". This is yet
another example of essentially redundant code
existence within CPT.

If an associated overlying bursa was
removed at same surgical session, it would most
likely be considered included in the more
comprehensive procedure - even though there is no
CCI edit link between the bone work and the bursa
excision - and not independently
reimbursed. Ultimately, reimbursement
of the bursa, in addition to the bone work, will
be dependent on the payer, and truly the degree of
separate work necessary to remove the bursa from
the overlying prominent bone.

The Haglund's deformity removal is not
necessary related to a posterior calcaneal spur
presence. They can occur together or one without
the other. The spur - many times being intra-
tendinous - presents more of a surgical
challenge - technically a different site on the
calcaneus, more exposure dissection, greater care
to avoid complete Achilles incision or detachment,
repair of the tendon and other soft tissue
(including possible anchoring of tendon), etc.
If performed solely (pun), the removal of the
posterior calcaneal spur would be coded,
CPT 28119 - ostectomy, calcaneus; for spur (with
or without plantar fascial release) - RVU 12.28 -
facility

[I would venture to assume the "low"
valuation because the procedure is commonly
thought - although not specifically defined - to
be the excision of an inferior calcaneal spur;
and that a spur is more localized that bossing
might be] or CPT 28118 - ostectomy, calcaneus
(ostectomy being
the surgical removal of bone) - RVU 13.99
facility or CPT 28120 - partial excision -
craterization,
saucerization - calcaneal bone for bossing
(bossing being a circular or knob-like
protuberance of bone) - RVU 15.92 facility
[assuming the spur is knobby]
Without specific CPT direction, the
surgeon must choose the code that best describes
what was there - we know it is bone, we know it's
a spur (a spur is also bone), and, well...can a
spur be bossy? Hmmm

Can one bill, CPT 28118 and CPT 28119,
excision of spur and ostectomy of calcaneus -
different deformities? Yes. with a "-59"
modifier on CPT 28118 (the higher valued
procedure).

Can one bill, CPT 28120 and CPT 28119, excision
of spur and ostectomy for bossing of calcaneus -
different deformities? Yes. with a "-59"
modifier on CPT 28120 (the higher valued
procedure).

The above are two examples of the lower
valued procedure being the comprehensive
procedure, while the higher valued procedures are
the component procedures. Again, ultimately,
reimbursement of the "component" bone procedure
and the "comprehensive" bone procedure will
depend on the payer's guidelines, and how
complete and compelling the operative report
is. If you honestly feel that both bone
procedures should be reimbursed, but the payer
refuses the second one, you can always append a
"-22"
modifier to the primary bone work, and submit the
operative report clearly evidencing the "above
and beyond" surgical work performed. And wait 4
months for the denial.

Harry Goldsmith, DPM

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