CPT code 28297 – Lapidus bunionectomy billing and coding

Key takeaways

CPT code 28297 reports a Lapidus bunionectomy, which fuses the first metatarsal and medial cuneiform joint instead of cutting the bone.

Sesamoidectomy is included in 28297 when performed and is never separately reportable.

The Akin osteotomy (CPT 28298) is a standalone hallux valgus code, so pairing it with 28297 follows current NCCI edits and payer policy.

CPT 28297 carries a 90-day global period, and related post-op E&M visits in that window are bundled into the surgical fee.

Pabau’s billing software checks eligibility in real time and submits CMS-1500 claims through Claim.MD, so coverage is confirmed before the surgery date.

CPT code 28297: Official descriptor and procedure overview

CPT code 28297 describes the Lapidus bunionectomy, a hallux valgus correction that fuses the first metatarsal and medial cuneiform joint. The fusion controls hypermobility at the first tarsometatarsal (TMT) joint. The American Medical Association maintains this code in its musculoskeletal surgery section. The descriptor’s “with sesamoidectomy when performed” wording means a sesamoid excision is included when the surgeon does one, and it is never reported separately.

CPT 28297 vs other hallux valgus correction codes

CPT code 28297 is the right choice when the surgeon fuses the first metatarsal and medial cuneiform joint. The neighboring codes correct the same deformity with a bone cut at a specific site instead. The surgical technique documented in the operative report decides the code, not the severity of the deformity.

The operative note must document fusion of the first TMT joint, including the fixation used, to support 28297. Without a fusion, the osteotomy site decides the code. A proximal metatarsal cut reports as 28295, and a distal metatarsal cut reports as 28296. An osteotomy of the proximal phalanx reports as 28298, and a double osteotomy as 28299. The label on the surgical schedule does not change that.

CPT 28290, the old simple bunionectomy code, has been deleted. A bunionectomy without an osteotomy or fusion now reports under 28292, which also covers resection of the proximal phalanx base when performed. The diagram below maps each code to the part of the first ray the surgeon works on.

What CPT code 28297 includes and excludes

The descriptor’s “with sesamoidectomy when performed” wording settles the most common bundling question. A sesamoid excision done during the Lapidus correction is included in 28297 and is never separately reportable. Billing CPT 28315 (sesamoidectomy, first toe) as its own line item breaks a National Correct Coding Initiative (NCCI) edit. Verify current NCCI pairings against the CMS Physician Fee Schedule before submission, because the edits update quarterly.

Modifiers for CPT code 28297

Modifier selection for CPT code 28297 depends on laterality, concurrent procedures, and circumstances that change the work involved. The table below covers the modifiers coders apply most often to 28297.

CMS guidance distinguishes modifier 59 from the X-modifier set (XS, XU, XE, XP). Many Medicare Administrative Contractors (MACs) now prefer XS (separate structure) over 59 for anatomically distinct companion procedures. A hammer toe correction on another digit is a common example. Check your MAC’s local policy before defaulting to 59.

Required documentation for CPT 28297 claims

Medical necessity is a common denial reason for CPT code 28297. Payers require objective evidence that conservative treatment failed and that the deformity meets clinical thresholds before approving a Lapidus fusion. Building a clean claim for 28297 starts with the pre-operative record, not the operative note.

The documentation checklist below reflects the elements most commercial payers and Medicare review contractors look for during medical necessity audits.

• Imaging with measurements: Weight-bearing X-rays documenting the intermetatarsal angle (IMA) and hallux valgus angle (HVA). Many payers require IMA above 15 degrees and HVA above 20 degrees to support surgical intervention, though thresholds vary by plan.
• Failed conservative therapy: A documented trial of non-surgical management, such as custom orthotics, wide toe-box footwear, and anti-inflammatory treatment. Payers usually expect it to run for a defined period, commonly three to six months.
• Functional impairment: Clinician notes describing pain with ambulation, shoe-fitting difficulty, or limitation in daily activities attributable to the hallux valgus deformity.
• Operative report elements: Explicit documentation of TMT joint preparation, cartilage removal, bone grafting if used, and internal fixation hardware with position and type.
• ICD-10-CM diagnosis codes: The primary code should be a laterality-specific hallux valgus code, M20.11 or M20.12, paired with 28297. Use M20.10 only when laterality is not documented.
• Prior authorization confirmation: PA reference number in the claim or attached documentation when required by the payer plan.

ICD-10 diagnosis codes paired with CPT code 28297

The primary pairing for CPT code 28297 is hallux valgus (acquired). Report M20.11 for the right foot, M20.12 for the left foot, or M20.10 when laterality is undocumented. The bunion codes M21.611, M21.612 and M21.619 are an alternative family, not a companion, because M20.1- carries an Excludes1 note for M21.6-.

Laterality is required by most payers. Submitting an unspecified code when the operative note documents a right or left foot procedure is a preventable denial. These codes update annually on October 1, so verify them against the CDC/NCHS ICD-10-CM web tool before each new fiscal year.

Code the family the clinical record supports, and never report both on one claim. If a claim denies on diagnosis grounds, check whether the payer’s local coverage determination (LCD) or coverage policy names the code family it accepts.

Medicare reimbursement and fee schedule for CPT code 28297

Medicare reimbursement for CPT code 28297 is based on the Medicare Physician Fee Schedule (MPFS), which uses relative value units (RVUs) to calculate payment. The work, practice expense, and malpractice RVUs are each adjusted for the practice location. Their sum is then multiplied by the annual conversion factor.

Use the FastRVU lookup tool to retrieve current work, practice expense, and malpractice RVU values for 28297 by year and locality. National averages are only a reference point. Reimbursement varies by locality through the geographic practice cost index (GPCI).

Global period for CPT 28297: What is and is not included

CPT 28297 carries a 90-day global period, classifying it as major surgery under the MPFS global surgery rules. The 90 days begin the day after the procedure. The following evaluation and management (E&M) visits and services are bundled into the surgical fee during this window. They may not be billed separately to Medicare.

• Bundled (not separately billable): The pre-operative visit the day before surgery and the E&M on the day of surgery are included. So are routine post-op visits during the 90 days and complications that need no return to the OR.
• Separately billable during global period: E&M visits for conditions unrelated to the surgery (modifier 24) and a return to the OR for complications (modifier 78). Staged procedures planned at the initial surgery (modifier 58) and services for a distinctly different diagnosis are also billable.

Document the reason for any post-op visit clearly. Payers audit global-period claims and will recoup E&M payments for visits that lack documentation showing an unrelated diagnosis or complication requiring distinct management.

Prior authorization requirements for CPT 28297

Traditional Medicare Part B does not require prior authorization (PA) for CPT 28297. Medicare Advantage plans (Part C) set their own PA rules, and many require it for elective foot surgery. Assuming Medicare never needs PA leads to denied claims for Medicare Advantage patients.

Commercial payers vary widely. Many require PA for a Lapidus bunionectomy, given the procedure’s elective classification and significant RVU weight. Common commercial PA criteria include the following.

• Documentation of conservative treatment failure over a defined period (typically three to six months)
• Weight-bearing X-rays with IMA and HVA measurements meeting the payer’s clinical thresholds
• Physician attestation of functional impairment affecting daily activities
• Operative plan specifying the Lapidus technique and internal fixation approach

Track PA status per patient and per payer in a structured workflow. A denied PA that goes unnoticed until claim submission costs the practice the full procedure fee.

Common claim denial reasons for CPT 28297 and how to avoid them

CPT code 28297 denials cluster around a predictable set of causes, and each one is preventable with the right pre-submission workflow. Knowing the common denial codes for surgical procedures helps billing teams spot the pattern before a claim goes out the door.

Tracking 28297 denial reasons by payer over time shows which plans flag claims on the same grounds. That record lets your team target appeals and adjust claims before the next submission.

How Pabau keeps CPT 28297 claims clean

Podiatric surgery billing runs on paperwork, and each manual handoff between the schedule, the operative note and the claim invites a denial. Good claims management software confirms coverage before the case is booked and follows each claim through to payment.

Pabau, the practice management platform we build, routes CPT 28297 claims through its Claim.MD clearinghouse integration. It submits CMS-1500 claims to thousands of US payers and checks eligibility in real time when you schedule the surgery. That way your team can confirm coverage and start the PA request before the case is booked.

Claim status updates and electronic remittance advice (ERA) come back into Pabau. Your team can follow each 28297 claim from submission to payment in one place, without chasing payers by phone.

Stop losing Lapidus reimbursement to preventable denials

Pabau checks eligibility in real time, submits CMS-1500 claims through Claim.MD, and returns claim status and ERA data. See how podiatric practices use it to get 28297 claims paid.

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Conclusion

Report 28297 only when the operative report documents a fusion of the first metatarsal and medial cuneiform joint. If the note describes a bone cut instead, the site of that cut picks the code, and rewording the claim cannot change it.

The money on a Lapidus case is protected long before submission. Lock in the hallux valgus diagnosis, the imaging angles and the prior authorization at scheduling, and the claim becomes routine.

Pabau checks eligibility in real time and submits CMS-1500 claims through Claim.MD, so your team catches coverage problems before the surgery date. Book a demo to see how it handles podiatric surgery billing from scheduling to remittance.

Continue your research

Need to understand how clearinghouse submission works for surgical codes? Pabau’s clearinghouse integration guide explains how claims route through Claim.MD to thousands of US payers.

Billing a hammer toe correction in the same session? CPT code 28285 covers how to report the hammer toe procedure itself.

Wondering how electronic remittance advice speeds up 28297 reconciliation? Electronic remittance advice (ERA) overview covers how 835 files map payment and adjustment codes back to surgical claims.

Looking for a complete revenue cycle walkthrough for your podiatric practice? Revenue cycle management guide covers the end-to-end process from eligibility check through payment posting.

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