Coding Corner Issue 2
The only CPT® code for a subtalar joint arthroeresis is: “CPT 0335T - Insertion of sinus tarsi implant”.
CPT 0035T is a Category 3 CPT code and, as such, there are third-party payers that may not pay for this service. As a result, pre-authorizing payment for this service is suggested before performing the procedure.
CPT coding determinations are made by the AMA CPT Editorial Panel and applications have been submitted to this Panel to get a Category 1 CPT code for subtalar arthroeresis more than once. The AMA CPT Editorial Panel indicated that the quantity and quality of the current peer-reviewed literature pertaining to subtalar arthroeresis does not warrant moving this CPT code from Category 3 to Category 1. Furthermore, the AMA CPT Editorial Panel is concerned about the lack of diversity of literature on this topic, as the overwhelming majority of literature is from one author.
I’m often asked if CPT 28899 is appropriate for sub-talar arthroeresis billing. CPT 28899 is defined as “Unlisted procedure, foot or toes.” This CPT code should only be used if the procedure performed is not listed anywhere in the CPT code set. It is inappropriate to use CPT 28899 for a subtalar arthroeresis because the procedure is, in fact, listed in the CPT code set. It is only listed in the Category 3 section of the CPT book, but it is listed. Therefore, an “unlisted” CPT code should not be used.
This is not an ideal situation and stakeholders continue to explore options in the effort to get a Category 1 CPT code for this service. Until then, it is recommended that providers attempt to prior authorize payment for this procedure before actually performing the procedure. If the third-party payer refuses to pay for the procedure, payment may fall to patient responsibility.
Author: Dr. Jeffrey Lehrman, DPM, FASPS, MAPWCA, CPC is the Orpyx Medical Director. He is a podiatrist, a Certified Professional Coder, and Certified Professional Medical Auditor.
Current Procedural Terminology (CPT®) is copyright 1966, 1970, 1973, 1977, 1981, 1983-2020 by the American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association (AMA). CPT codes and their descriptions do not reflect or guarantee coverage or payment. The existence of a CPT code does not guarantee payment for the service it describes. Coverage and payment policies of governmental and private payers vary from time to time and for different areas of the country. Questions regarding coverage and payment by a payer should be directed to that payer. Orpyx does not claim responsibility for any consequences or liability attributable to the use of any information, guidance, or advice contained in this email. Only providers are responsible for their coding choices.