Coding Principles for CPT Code 28297 – Decoding Bunionectomy Procedures

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By Paul Cadorette, CPC, COC, CPC-P, COSC, CASCC, Director of Education, nimble solutions

This post was updated on November 21, 2023 to reflect changes made in the 2024 CPT Manual Guidelines.

I covered CPT code 28297 in the 2023 Ankle, Foot and Toes Orthopedic Surgery Coding Course. Based on New Parenthetical Notes in the 2024 CPT Manual, I find it necessary to revise my coding recommendation for bunionectomy and CPT code 28297.

As of January 1, 2024, there will be some crucial changes to how this code is to be interpreted. In this blog post, I’ll explain the updates to CPT code 28297 by pointing out what coding principles are still in effect for 2023 – referencing important takeaways from two CPT Assistant articles from December 2016 and April 2021 related to bunionectomy coding – and detail what changes are to be made in 2024.

If you want to know more about 2024 and 2025 CPT updates, you can register for the 2025 CPT Code Changes coding course. I’ll review CPT code 28297, plus detail all the coding information you need to know to start the year off on the right track.

Understanding the complexity of bunion deformities

Bunion deformities, specifically hallux valgus, vary in pathology and severity. Therefore, it is vital to define them in terms of complexity rather than considering them as a single deformity.

The December 2016 CPT Assistant article emphasizes the diverse nature of these deformities and lists eight different contributing conditions, two of which are metatarsus primus varus and malalignment of the first metatarsal sesamoid apparatus.

The role of Lapiplasty Techniques

A notable device used to correct hallux valgus is the Lapiplasty technique. This innovative method involves rotating the metatarsal head to realign the sesamoid bones and reduce the intermetatarsal angle. By adopting this technique, surgeons can address specific complexities of the bunion deformity effectively.

Components of surgical correction

The CPT Assistant article provides valuable insights into the surgical correction of bunion deformities by listing 20 different services included in the procedure. However, it is essential to understand that not all 20 services need to be performed in order to use CPT code 28297.

The AMA clarifies that “Bunionectomy procedures include IF PERFORMED the following components.”

By stating “if performed” the AMA is indicating that the 20 listed services don’t all have to be performed, but any of those services are considered part of the bunion correction if they are performed.

Interestingly enough, one of those inclusive services is “resection of medial, dorsomedial, dorsal, and/or dorsolateral bone prominences at the metatarsal head.”

Clarification on excision of medial eminence

A significant question that often arises in bunionectomy coding is whether the excision of the medial eminence is necessary for reporting hallux valgus correction with CPT code 28297.

The CPT Assistant December 2016 article and the subsequent April 2021 article provide valuable answers.

Based on the information presented, it is not mandatory to excise the medial eminence for coding hallux valgus correction with CPT code 28297.

The illustrations in the CPT Manual showcasing excision of the medial eminence are just one treatment example among various pathology and treatments associated with the condition.

Supporting evidence

The CPT Assistant April 2021 article further supports this clarification: In a scenario where a hallux valgus correction is performed with first metatarsal cuneiform joint fusion, but no bunion excision is involved, CPT code 28297 would be the appropriate code to report.

This reinforces the understanding that the excision of the medial eminence is not a mandatory component for coding hallux valgus correction.

2024 changes to CPT code 28297 and CPT code 28740

A recent comment was made by the AMA that “users mistakenly believed you report a hallux valgus correction regardless of whether a bunion was resected or not.”

I will agree that the illustrations and code explanations from the December 2016 CPT Assistant show the medial eminence being removed, but the coding advice never stated this was a REQUIRED component of a bunionectomy. Instead, it was stated that removal of medial was an inclusive service “IF PERFORMED.”

The CPT Assistant from April 2021 answered the question: “What code should be reported for 1^st TMTJ arthrodesis when no bunion is removed?” The definitive answer was that 28297 should be reported.

If there were any “mistaken beliefs” regarding this code, it was because of the information that had been published by the AMA.

That leads us to a parenthetical note found under CPT code 28297 in the 2024 CPT Manual which states:

(For first metatarsal-cuneiform joint fusion without concomitant removal of the distal medial prominence of the first metatarsal for hallux valgus correction, use 28740).

This coding recommendation is telling us that when reporting a bunionectomy CPT code the medial eminence MUST be excised/removed.

This issue is driven by the Lapiplasty procedure, so whenever this device is used to correct an increased intermetatarsal angle with fusion of the 1^st TMTJ and the medial eminence IS NOT removed, you should report CPT code 28740 rather than 28297.

Additional 2024 updates for CPT 28297

With regards to additional procedures impacted by 2024 updates for CPT 28297, during the recent AMA CPT Editorial Panel Symposium, the issue of “separate procedure” was discussed not only by panel members but also CMS representatives and the consensus was that for a code labeled with the separate procedure designation – the service must be separate and distinct and not associated with the primary service.

Per Lapiplasty protocol, the device used during this treatment assists in rotating the metatarsal back into the correct anatomical alignment. To accomplish this, a capsulotomy is first performed at the metatarsal head. Then the rotation of the metatarsal is necessary for the overall successful completion of this service. It is my recommendation that CPT code 28270 should not be reported, since this process does not represent two separate and distinct services or procedures.

I have asked the AMA for clarification on this next point of contention because of differences of opinion on this coding scenario:

The physician performs a 1^st TMTJ fusion along with McBride and/or Akin bunionectomy procedures. In this case, the medial eminence is excised, so would you report 28297 or 28740 for the 1^st TMTJ fusion? Providers will state the medial eminence was removed as part of one of the other services, but the guideline simply states without concomitant removal of the distal medial prominence of the first metatarsal for hallux valgus correction.

If you go back to the CPT Assistant December 2016 article, you will see that hallux valgus and increased first intermetatarsal angle are two conditions that represent types of bunion pathology, so is the provider able to pick and choose which primary service excision of the medial eminence is associated with? Stay tuned as I’ll provide additional updates on this information when it becomes available.

Final thoughts on coding principles for CPT Code 28297

Ensuring accurate orthopedic coding for procedures like bunionectomy requires a thorough understanding of the complexities associated with the condition. By referring to CPT Assistant articles and published information provided by the AMA, medical professionals can gain valuable insights into correct coding principles for CPT code 28297.

Remember, the CPT Manual serves as an authoritative resource, and the AMA’s guidance should be followed for accurate coding and billing. Being aware of the nuances in bunion deformities and the Lapiplasty technique can help surgeons choose the appropriate coding for each unique case, leading to better patient care and proper reimbursement.

Always stay updated with the latest CPT Assistant articles and utilize reliable resources to enhance your coding knowledge and stay compliant in the ever-evolving field of orthopedic coding.

This blog post outlines some of the topics covered in the 2023 Ankle, Foot and Toes coding course, available on demand with corresponding AAPC continuing education units included.

References:

CPT Assistant December 2016 page 3

CPT Assistant April 2021 page 13

Current Procedural Terminology is copyright by the American Medical Association.