Percutaneous skeletal fixation of a talus fracture performed with manipulation, using pins or screws inserted through the skin without open exposure of the fracture site.

Verified May 8, 2026 · 5 sources ↓

Medicare: $497.01
Work RVU: 4.78
Global, days: 90
Region: Foot & ankle

Drawn from CMSAAPCCgsmedicare

Documentation requirements

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

Source · Editorial brief grounded in 5 cited references ↓

Mechanism of injury documented (high-energy trauma: MVA, fall from height, etc.)
Fracture pattern and displacement described in the operative report
Fluoroscopic confirmation of reduction and fixation placement noted
Type, size, and number of percutaneous fixation devices (K-wires, cannulated screws) specified
Operative note explicitly states percutaneous technique — no formal open incision
Laterality (left or right foot) documented in the operative report and on the claim

Applicable modifiers

Modifiers commonly billed with this code.

Source · AMA CPT modifier descriptors · CMS NCCI Policy Manual

22 Increased complexity 51 Multiple procedures 57 Decision for surgery 58 Staged or related 78 Unplanned return — related 79 Unrelated during global 80 Assistant surgeon AS PA/NP/CNS assistant LT Left side RT Right side

What this code covers

Source · Editorial summary grounded in 5 cited references ↓

CPT 28436 describes percutaneous skeletal fixation of a talus fracture with manipulation. The surgeon reduces the fracture manually or with closed instrumentation, then drives fixation hardware — typically Kirschner wires or cannulated screws — through small stab incisions under fluoroscopic guidance, without formally opening the fracture. This distinguishes 28436 from open treatment (28445), which involves direct visualization and internal fixation through a formal incision, and from closed treatment with manipulation (28435), which uses no internal fixation at all.

Talus fractures are almost exclusively high-energy injuries — motor vehicle accidents, falls from height, or dashboard impacts. When the fracture pattern is reducible but unstable enough to require fixation, 28436 is the appropriate code. Document the fracture pattern, mechanism of injury, the fluoroscopic confirmation of reduction, the number and type of fixation devices placed, and the specific percutaneous technique used. Operative notes that lack detail on fixation hardware type or fail to confirm fluoroscopic guidance invite downcoding to 28435.

The 90-day global period covers the procedure day and all routine postoperative management through day 90. A separate E/M on the day of surgery requires modifier 57 — not 25 — because this is a major procedure. Return trips to the OR for related complications (hardware failure, loss of reduction) within the global period use modifier 78; unrelated procedures use modifier 79.

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 (4.78) is the surgeon's own effort — the figure physician pay and productivity targets are built on. The total RVU (14.88) adds practice overhead and malpractice, and is what drives the Medicare payment below.

Work RVU	4.78
Practice expense RVU	9.07
Malpractice RVU	1.03
Total RVU	14.88
Medicare national rate	$497.01
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	$497.01
HOPD (APC 5114) Hospital outpatient department	$7,413.38
ASC (PI J8) Ambulatory surgical center (freestanding)	$5,135.87

Common denial reasons

The recurring reasons claims for CPT 28436 get rejected.

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

Operative note describes open exposure, triggering downcoding to 28445
Lack of fluoroscopic guidance documentation causes payer to question percutaneous technique
Modifier 25 used instead of modifier 57 on a same-day E/M decision for surgery
Missing laterality modifier when required by the payer
Unbundling denied when imaging guidance is billed separately but is integral to the percutaneous fixation

Frequently asked questions

Source · Generated from the editorial pipeline, verified against 5 cited references ↓

01What separates 28436 from 28435 and 28445?

28435 is closed treatment with manipulation and no internal fixation. 28436 adds percutaneous hardware without opening the fracture. 28445 is open treatment with formal incision and direct visualization. The operative note must make the approach and fixation method unambiguous.

02Which modifier goes on a same-day E/M when surgery is decided at that visit?

Use modifier 57 on the E/M code. Because 28436 carries a 90-day global period, it is a major procedure. Modifier 25 applies only to procedures with 0- or 10-day globals. Using 25 here will trigger a denial.

03Can fluoroscopic guidance be billed separately with 28436?

No. Fluoroscopy is integral to percutaneous fixation. Per NCCI policy, when a code's technique inherently requires fluoroscopic guidance, a separate radiology guidance code cannot be billed for the same procedure on the same date.

04If the patient returns to the OR during the 90-day global for hardware removal or loss of reduction, what modifier applies?

Use modifier 78 for a return to the OR for a related procedure during the postoperative period. If the return procedure is completely unrelated to the talus fixation, use modifier 79.

05Is laterality required on claims for 28436?

Medicare does not mandate LT/RT modifiers on foot fracture codes the way it does for some bilateral procedures, but many commercial payers and some MACs require them. Append LT or RT when the payer requires laterality, and document it in the operative report regardless.

06Can 28436 be billed with an assistant surgeon?

Yes, when medical necessity supports it. The assisting physician bills with modifier 80; a PA, NP, or RNFA uses modifier AS. Supporting documentation should reflect why assistance was medically necessary for the complexity of the fixation.

Sources & references

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

Mira Scribe

Mira's AI scribe captures the mechanism of injury, fracture pattern, manipulation technique, fluoroscopic guidance confirmation, and the specific percutaneous fixation devices used (type, size, quantity) directly from dictation. This prevents the most common audit flag for 28436 — an operative note that reads as open treatment or omits hardware detail — which drives downcoding to 28435 or 28445.

See how Mira captures CPT 28436 documentation