03/13/2026    David Freedman, DPM

Filed Closed Reduction

I recently had a patient that came into the office
with a completely dislocated hallux
interphalangeal joint. I anesthetized the patient
and attempted to close reduce the fracture
dislocation and was unsuccessful. He will go to
the operating room at a later date.

How do I bill this office visit? What modifier do
I use for the multiple sets of x-rays I took in
the office?

Codinghelpline.com response: Based on your
description, this appears to be a displaced
fracture involving the hallux phalanx with
associated interphalangeal joint involvement,
rather than a simple dislocation. Although the IPJ
was dislocated, the presence of a fracture makes
this more than a straightforward dislocation case.

From a billing standpoint, this encounter would
generally be reported as a procedure rather than
an E/M office visit, unless you provided and
documented a separately identifiable evaluation
and management service unrelated to the reduction
attempt.

1.For the attempted closed reduction, you would
report:

CPT 28495-52-RT (or LT) Closed treatment of
fracture, great toe, phalanx or phalanges; with
manipulation.

Closed fracture care codes inherently include the
anesthesia typically required for the procedure,
so a separate anesthesia charge is not reported.

Because your attempt at closed reduction was
unsuccessful and the patient will require a more
extensive surgical procedure at a later date, you
would append Modifier 52 (Reduced Services).
Modifier 52 is appropriate when a service or
procedure is partially reduced or discontinued at
the physician’s discretion. Your documentation
should clearly state that a closed reduction was
attempted but unsuccessful, and that the patient
will require a staged operative intervention at a
future date.

2.Regarding the in office radiographs: If you
performed a complete foot series such as CPT
73630-RT (or LT) and then repeated the same series
during the same encounter (for example, pre- and
post-reduction attempts), the repeat study would
be billed with Modifier 76 (Repeat procedure or
service by same physician).

Example:

73630-RT

73630-76-RT

Be sure your documentation supports medical
necessity for the repeat imaging (e.g., pre-
reduction and post-attempt evaluation).

David Freedman, DPM, Silver Spring, MD

Additional coding and billing questions and
responses can be found at Codinghelpline.com

Other messages in this thread:

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03/13/2026    David Freedman, DPM

Filed Closed Reduction

I recently had a patient that came into the office
with a completely dislocated hallux
interphalangeal joint. I anesthetized the patient
and attempted to close reduce the fracture
dislocation and was unsuccessful. He will go to
the operating room at a later date.

How do I bill this office visit? What modifier do
I use for the multiple sets of x-rays I took in
the office?

Codinghelpline.com response: Based on your
description, this appears to be a displaced
fracture involving the hallux phalanx with
associated interphalangeal joint involvement,
rather than a simple dislocation. Although the IPJ
was dislocated, the presence of a fracture makes
this more than a straightforward dislocation case.

From a billing standpoint, this encounter would
generally be reported as a procedure rather than
an E/M office visit, unless you provided and
documented a separately identifiable evaluation
and management service unrelated to the reduction
attempt.

1.For the attempted closed reduction, you would
report:

CPT 28495-52-RT (or LT) Closed treatment of
fracture, great toe, phalanx or phalanges; with
manipulation.

Closed fracture care codes inherently include the
anesthesia typically required for the procedure,
so a separate anesthesia charge is not reported.

Because your attempt at closed reduction was
unsuccessful and the patient will require a more
extensive surgical procedure at a later date, you
would append Modifier 52 (Reduced Services).
Modifier 52 is appropriate when a service or
procedure is partially reduced or discontinued at
the physician’s discretion. Your documentation
should clearly state that a closed reduction was
attempted but unsuccessful, and that the patient
will require a staged operative intervention at a
future date.

2.Regarding the in office radiographs: If you
performed a complete foot series such as CPT
73630-RT (or LT) and then repeated the same series
during the same encounter (for example, pre- and
post-reduction attempts), the repeat study would
be billed with Modifier 76 (Repeat procedure or
service by same physician).

Example:

73630-RT

73630-76-RT

Be sure your documentation supports medical
necessity for the repeat imaging (e.g., pre-
reduction and post-attempt evaluation).

David Freedman, DPM, Silver Spring, MD

Additional coding and billing questions and
responses can be found at Codinghelpline.com