AHA Coding Clinic® for HCPCS - 2023 Issue 2; Ask the Editor

Distal Syme's amputation of left second toe

A patient with ulcer, osteomyelitis and exposed distal second toe phalanx presented for a distal Syme’s amputation. Attention was directed to the left second digit where a fishmouth incision was created with a #15 blade at the level of the proximal interphalangeal joint. The incision was deepened and with an oscillating bone saw, approximately one-half of the proximal phalanx was resected. The proximal margin was inked and the toe was sent for pathological examination. Is either CPT code 28124 or 28160 appropriate for this case? How is the Syme’s toe amputation reported? ...

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