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2025 CPT code 28113

Complete excision of the fifth metatarsal head.

The application and removal of the first cast, splint, or traction device is included in the code. Subsequent replacements may be reported separately. If a cast is removed by someone other than the physician who applied it, a cast removal code should be used.

Modifiers may be applicable. Modifier 51 (Multiple Procedures) is used if significant additional procedures are performed during the same session. Modifier 76 (Repeat Procedure or Service) applies if the procedure is repeated by the same physician.

Medical necessity must be established by documenting the underlying condition necessitating the procedure. The documentation should clearly demonstrate failed conservative treatment options and the severity of symptoms affecting the patient's function and quality of life.

In simple words: This procedure removes the bone at the base of your little toe. The surgeon makes a small cut near the toe joint, carefully moves aside the tissues under the skin, and removes the end of the bone. They may use pins or a cast to keep the toe stable while it heals.

The surgical removal of the entire fifth metatarsal head. This procedure involves an incision at the fifth metatarsophalangeal joint, dissecting through subcutaneous tissue while protecting nerves and vessels. The joint capsule and any diseased synovium are removed, exposing the metatarsal head for complete excision. Post-excision, pins or wires may be inserted for stabilization, often followed by a cast application.

Example 1: A patient presents with severe pain and limited mobility in their little toe due to avascular necrosis (bone death) of the fifth metatarsal head. After conservative treatments fail, a decision is made to perform a complete excision of the fifth metatarsal head (CPT code 28113)., A patient with a chronic infection (osteomyelitis) in the fifth metatarsal head, unresponsive to antibiotics, undergoes a complete excision of the affected bone (CPT code 28113) to eliminate the infection., Following a traumatic injury to the forefoot, a patient suffers a severely comminuted fracture (bone broken into many pieces) of the fifth metatarsal head. Surgical intervention is required, and the surgeon performs a complete excision of the fifth metatarsal head (CPT code 28113) due to the complexity of the fracture.

Preoperative diagnostic imaging (X-ray, MRI, or CT scan) to assess the extent of bone damage, operative report detailing the procedure, including the size of the incision and any complications, and post-operative care plan.

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