Dislocation CPT Codes: Traumatic vs Non-traumatic

Dislocation CPT Codes: Traumatic vs Non-traumatic

January 9, 2020

Question:
Is it appropriate to report CPT code 28645 for both traumatic and non-traumatic dislocations?

Answer:
Yes, CPT code 28645 (Open treatment of metatarsophalangeal joint dislocation, includes internal fixation, when performed) may be reported whether the nature of the dislocation is traumatic or non-traumatic, as long as the dislocation required an open treatment. The diagnosis code will differentiate the condition as traumatic or non-traumatic.

Four CPT codes exist for the treatment of metatarsophalangeal joint dislocations. Report the appropriate code based on the type of treatment:
28630: Closed treatment, no anesthesia required
28635: Closed treatment, anesthesia required
28636: Percutaneous treatment, with manipulation
28645: Open treatment, with internal fixation, when performed

*This response is based on the best information available as of 01/09/20.

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