A calcaneal fracture is a break in the heel bone, an injury that can significantly impact mobility. The healthcare system uses medical coding to ensure proper communication and reimbursement for treatment. This process translates the physician’s service into alphanumeric codes recognized by insurers.
Accurate coding is necessary for the facility and the provider to receive payment for managing the broken bone. The chosen treatment method determines which codes are used, making detailed documentation critically important.
Identifying the Specific Procedure Code
For a closed treatment of a calcaneal fracture requiring manual realignment, the Current Procedural Terminology (CPT) system assigns code 28405. This five-digit code is found in the musculoskeletal section of the CPT manual under procedures on the foot and toes.
The description, “Closed treatment of calcaneal fracture; with manipulation,” matches a non-surgical correction of a heel bone break. “Closed treatment” confirms the skin was not surgically opened to access the fracture site.
This single code is comprehensive and encompasses all typical components of the fracture care provided on that day. Included in the reimbursement for CPT 28405 are the manipulation of the bone fragments, necessary anesthesia or sedation, and the initial application of immobilization devices.
This application might involve a cast, splint, or fracture boot used to stabilize the heel bone after realignment. Because these associated services are integral to the fracture treatment, they cannot be billed separately.
Defining the Role of Manipulation in Coding
The term “with manipulation” is the most important factor determining the correct CPT code selection. Manipulation, or reduction, is the physical maneuvering of displaced fractured bone fragments back into an acceptable anatomical position.
The physician’s detailed notes on the effort to restore alignment justify using the more complex code.
If the fracture were non-displaced (fragments remained in good alignment), manual reduction would not be required. The correct code would then be CPT 28400, “Closed treatment of calcaneal fracture; without manipulation.”
The distinction between CPT 28405 and 28400 reflects a significant difference in complexity, time, and risk, as manipulation often requires conscious sedation or regional anesthesia. The medical record must clearly document the manual reduction technique and confirmation of acceptable post-reduction alignment, usually via fluoroscopy or X-rays, to support the manipulation code.
Assigning Laterality and Global Coverage
Since the procedure was performed on the left foot, CPT code 28405 must be appended with the laterality modifier -LT (Left side). Laterality modifiers provide specific detail about the body part treated, which is crucial for paired structures like the feet.
The full procedural code submitted for billing is 28405-LT. This combination accurately communicates to the payer that the complex, closed treatment with manipulation was specifically directed at the left calcaneal fracture.
CPT 28405 falls under the Global Surgical Package, which typically assigns a 90-day global period. This package is a bundled payment system intended to cover all routine care associated with the procedure for a set time frame.
The 90-day period begins the day of the procedure and includes all standard post-operative services performed by the same treating physician. Routine follow-up office visits, necessary X-rays to check healing, and routine cast or splint changes during these three months are part of the initial payment for 28405-LT.
Separate billing for these routine post-operative services is inappropriate and could result in claim denial or recoupment of funds by the payer. Services not included in the global package, such as treatment for an unrelated condition or an unplanned surgery for a complication, can be billed separately.
The physician must use specific modifiers to indicate that a service during the global period was distinct from standard follow-up care.
Essential Documentation and Billing Factors
Beyond the CPT code, the claim requires a corresponding diagnosis code, known as an ICD-10-CM code. This code identifies the specific injury, which is a fracture of the calcaneus.
The ICD-10 code must be highly specific, detailing the fracture’s location (e.g., body, neck, or process), laterality, and the encounter type (initial treatment or subsequent encounter).
The physician’s procedure note is the ultimate source of truth for the entire claim and must meticulously describe the procedure performed. This note should confirm the treatment was closed, detail the steps of the manual manipulation, and verify the application of the definitive immobilization device.
The setting of the service also impacts billing, as facility billing and professional fee billing are processed separately. Successful reimbursement relies on the combination of an accurate CPT code, the correct laterality modifier, and a highly specific ICD-10 code, all supported by thorough documentation.