Surgical excision of one or both sesamoid bones at the first metatarsophalangeal joint, performed as a standalone procedure when conservative management has failed.

Verified May 8, 2026 · 7 sources ↓

Medicare: $481.31
Work RVU: 4.88
Global, days: 90
Region: Foot & ankle

Drawn from CMSAAPCMDeMedNY PodiatryAACPM

Documentation requirements

What must appear in the operative or office note to support the claim.

Source · Editorial brief grounded in 7 cited references ↓

Specify which sesamoid was removed: tibial (medial) or fibular (lateral), or both.
Document failure of conservative treatments (orthotics, injections, physical therapy) prior to surgery.
Include pre-operative imaging (X-ray or MRI) confirming sesamoid pathology — fracture, osteonecrosis, arthritis, or hypertrophy.
Operative note must name the surgical approach (plantar, dorsomedial, or other) and describe tendon handling to confirm preservation of the flexor hallucis brevis.
Record laterality (left or right foot) explicitly in both the operative note and diagnosis coding.
State the clinical indication with specificity — sesamoiditis, fracture, osteonecrosis, or structural abnormality — to support medical necessity.

Applicable modifiers

Modifiers commonly billed with this code.

Source · AMA CPT modifier descriptors · CMS NCCI Policy Manual

22 Increased complexity 24 Unrelated E/M during global 25 Significant separate E/M 50 Bilateral procedure 51 Multiple procedures 52 Reduced services 58 Staged or related 59 Distinct service 76 Repeat, same physician 78 Unplanned return — related 79 Unrelated during global 80 Assistant surgeon LT Left side RT Right side

What this code covers

Source · Editorial summary grounded in 7 cited references ↓

CPT 28315 covers sesamoidectomy of the first toe — the surgical removal of the tibial or fibular sesamoid bone (or both) seated beneath the first metatarsophalangeal joint. The procedure is indicated for sesamoiditis refractory to conservative care, sesamoid fracture with nonunion, osteonecrosis, or chronic arthritic changes that cause persistent plantar pain under the hallux. The surgeon makes a plantar or dorsomedial incision, carefully dissects around the flexor hallucis brevis tendon, and excises the offending bone while preserving tendon function and joint stability.

The code descriptor includes the designation 'separate procedure,' which carries significant billing consequences. Per CMS NCCI policy, 28315 cannot be billed separately when performed on the ipsilateral first toe or metatarsal in conjunction with any bunionectomy code (28291–28299). If sesamoidectomy adds substantial complexity to an otherwise standalone bunionectomy, modifier 22 with supporting documentation is the appropriate path — not unbundling 28315 as an add-on. The 90-day global period means all routine post-op care, dressing changes, and related visits through day 90 are included in the base payment.

RVU & reimbursement

Component RVUs and Medicare national rate. Actual payment varies by GPCI locality.

Source · CMS Physician Fee Schedule, RVU26A · January 2026

Work RVU vs. total RVU

The work RVU (4.88) is the surgeon's own effort — the figure physician pay and productivity targets are built on. The total RVU (14.41) adds practice overhead and malpractice, and is what drives the Medicare payment below.

Work RVU	4.88
Practice expense RVU	8.99
Malpractice RVU	0.54
Total RVU	14.41
Medicare national rate	$481.31
Global period	90 days

Payment by site of service

Medicare pays different rates by setting. HOPD typically pays substantially more than ASC for the same procedure.

Source · CMS OPPS Addendum B·ASC HCPCS payment rates·2026

Setting	Medicare rate (national)
Office (PFS non-facility) Procedure performed in physician's office	$481.31
HOPD (APC 5113) Hospital outpatient department	$3,342.87
ASC (PI A2) Ambulatory surgical center (freestanding)	$1,644.87

Common denial reasons

The recurring reasons claims for CPT 28315 get rejected.

Source · Editorial brief grounded in CMS NCCI edits, AAOS coding appeals, and cited references ↓

Billed alongside bunionectomy codes 28291–28299 on the ipsilateral foot without modifier 22 — NCCI prohibits separate payment in this scenario.
Missing documentation of failed conservative treatment, triggering medical necessity denial.
Laterality not specified on claim — payer unable to adjudicate without LT or RT modifier.
Diagnosis code too vague (e.g., unspecified foot pain) without imaging or clinical findings tying to sesamoid pathology.
Global period conflict — post-op visit billed within the 90-day window without modifier 24 when the visit is for an unrelated condition.

Frequently asked questions

Source · Generated from the editorial pipeline, verified against 7 cited references ↓

01Can I bill 28315 alongside a bunionectomy on the same foot?

No. CMS NCCI policy explicitly prohibits billing 28315 separately with any bunionectomy code (28291–28299) performed on the ipsilateral first toe or metatarsal. The 'separate procedure' designation in the code descriptor is the mechanism CMS uses to enforce this. If the sesamoidectomy substantially increased operative complexity, append modifier 22 to the bunionectomy code and document why the work exceeded typical.

02Does 28315 require modifier 59 when billed with 28122?

No. NCCI allows 28315 and 28122 to be billed together without modifier 59, because they describe distinct procedures that are not bundled under current edits. Confirm current NCCI edit status before each billing cycle, as edits are updated quarterly.

03What modifier applies if both sesamoids are excised on both feet at the same session?

Use modifier 50 to indicate a bilateral procedure. If only one foot is involved, append LT or RT. Most payers expect laterality modifiers on foot procedures regardless of whether both feet are treated.

04What ICD-10 codes typically support medical necessity for 28315?

Common supporting diagnoses include M25.371/M25.372 (stiffness of ankle and foot joints), M79.671/M79.672 (pain in foot), M84.371/M84.372 (stress fracture of foot), and M87.271/M87.272 (osteonecrosis, ankle and foot). The diagnosis should match the pathology confirmed on imaging — sesamoiditis, fracture, or osteonecrosis — not a generic foot pain code.

05How does the 90-day global period affect post-op billing?

All routine post-op visits, wound checks, and dressing changes through day 90 are bundled into the 28315 payment. If you see the patient within 90 days for a condition unrelated to the sesamoidectomy, bill the E&M with modifier 24. A related but unplanned return to the OR for a complication takes modifier 78.

06Is modifier 22 ever appropriate with 28315 as a standalone procedure?

Yes — if the sesamoidectomy itself required substantially increased operative work (dense adhesions, aberrant anatomy, or bilateral excision requiring separate incisions documented as unusually complex), modifier 22 is appropriate on 28315 directly. The operative note must quantify why the work exceeded typical. Without that detail, modifier 22 claims will be denied.

Sources & references

Editorial content was developed using the following public sources. Last verified May 8, 2026.

01CMS Physician Fee Schedule 2026
02CMS NCCI Policy Manual Chapter 4, Section IV-18, Item 14 (Revision Date 1/1/2024) — https://www.cms.gov/files/document/medicare-ncci-policy-manual-2024-chapter-4.pdf
03AAPC Codify CPT 28315 — https://www.aapc.com/codes/cpt-codes/28315
04MD Clarity CPT Code 28315 — https://www.mdclarity.com/cpt-code/28315
05eMedNY Podiatry Procedure Codes (April 2026) — https://www.emedny.org/ProviderManuals/Podiatry/PDFS/Podiatry_Procedure_Codes.pdf
06AACPM Unofficial PRR and CPT Code Guide — https://aacpm.org/wp-content/uploads/COTH-Unofficial-PRR_CPT-Guide.pdf
07Podiatry Management Online, Codingline Corner: Excision of Sesamoid Coding (04/05/2008) — https://www.podiatrym.com/search3.cfm?id=18824

Mira AI Scribe

Mira's AI scribe captures the sesamoid laterality (tibial vs. fibular), surgical approach by name, tendon management details, and the documented history of failed conservative care from the surgeon's dictation. This prevents the two most common denial triggers: vague operative notes that omit approach and bone identity, and missing prior-treatment history that payers require to establish medical necessity for sesamoidectomy.

See how Mira captures CPT 28315 documentation