Percutaneous skeletal fixation of a metatarsophalangeal joint dislocation, performed with manipulation

Verified May 8, 2026 · 4 sources ↓

Medicare: $388.12
Work RVU: 2.7
Global, days: 10
Region: Foot & ankle

Drawn from CMSAbosAAOS

Documentation requirements

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

Source · Editorial brief grounded in 4 cited references ↓

Confirm the joint level: specify which metatarsophalangeal joint(s) were dislocated and treated
Document that manipulation (closed reduction) was performed prior to or concurrent with fixation
Record that percutaneous skeletal fixation was placed — include hardware type, size, and number of pins
Describe fluoroscopic or imaging confirmation of reduction and hardware position intraoperatively
Note laterality explicitly (left, right, or bilateral) in the operative report header and body
Include the mechanism of injury or clinical indication supporting the dislocation diagnosis

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 73 Discontinued pre-anesthesia 74 Discontinued post-anesthesia 76 Repeat, same physician 77 Repeat, another physician 78 Unplanned return — related 79 Unrelated during global LT Left side RT Right side

What this code covers

Source · Editorial summary grounded in 4 cited references ↓

CPT 28636 covers the closed reduction and percutaneous pin fixation of a dislocated metatarsophalangeal (MTP) joint in the foot. The procedure involves manipulating the dislocated joint back into anatomical alignment and then stabilizing it with percutaneous skeletal fixation — typically K-wires placed through the skin without a formal open incision. Fluoroscopic guidance is typically used to confirm reduction and hardware placement, though fluoroscopy is generally considered bundled into the procedure and not separately billable.

This code sits in the middle of a three-tier hierarchy for MTP joint dislocations: closed reduction without fixation (28630), percutaneous fixation with manipulation (28636), and open treatment with internal fixation (28645). Selecting the right code requires operative note documentation that confirms both the manipulation and the percutaneous fixation — if only manipulation was performed without hardware, 28636 is not correct. The 10-day global period means post-op visits within that window are included in the surgical payment; unrelated E/M services require modifier 24.

Bilateral MTP dislocations treated in the same session require modifier 50 or laterality modifiers LT/RT with appropriate payer-specific billing conventions. Commercial payer policies on percutaneous foot fixation vary; some require prior authorization or specific ICD-10 diagnosis pairing, particularly for non-traumatic presentations.

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 (2.7) is the surgeon's own effort — the figure physician pay and productivity targets are built on. The total RVU (11.62) adds practice overhead and malpractice, and is what drives the Medicare payment below.

Work RVU	2.7
Practice expense RVU	8.35
Malpractice RVU	0.57
Total RVU	11.62
Medicare national rate	$388.12
Global period	10 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	$388.12
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 28636 get rejected.

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

Billing 28636 when only manipulation was performed without percutaneous fixation — correct code is 28630
Missing laterality in the claim or operative note, triggering a payer edit requiring clarification
Unbundling fluoroscopy (77002) separately when it is considered integral to the percutaneous fixation
Post-op E/M visit billed within the 10-day global without modifier 24 for an unrelated condition
ICD-10 diagnosis code mismatch — using a sprain or fracture code instead of a dislocation code (e.g., S93.1xx)

Frequently asked questions

Source · Generated from the editorial pipeline, verified against 4 cited references ↓

01What separates 28636 from 28630 and 28645?

28630 is closed reduction of an MTP dislocation without fixation. 28636 requires both manipulation and percutaneous pin fixation. 28645 is the open procedure with internal fixation. The operative note must support whichever tier you bill — hardware placement is the dividing line between 28630 and 28636.

02Can fluoroscopy be billed separately with 28636?

Generally no. Fluoroscopic guidance used to confirm reduction and hardware placement is considered integral to percutaneous fixation procedures and is bundled under NCCI policy. Check current NCCI edits before appending 77002; most payers will deny it without a strong distinct-service argument.

03How is a bilateral MTP dislocation billed in the same session?

Use modifier 50 if your payer accepts bilateral billing on a single line, or bill two lines with LT and RT modifiers. Document each joint separately in the operative note. Reimbursement typically does not exceed 150% of the single-procedure fee schedule amount for bilateral cases.

04What global period applies to 28636, and what does it cover?

28636 carries a 10-day global period (CMS Physician Fee Schedule 2026). That covers the procedure day and routine post-op care through day 10. Any unrelated E/M service in that window requires modifier 24; a new problem requiring a separate decision requires modifier 25 if billed same-day as the procedure.

05If the reduction fails and the patient returns for open treatment within the global, how is that billed?

A return to the OR for open treatment (28645) because the percutaneous fixation failed is a related procedure during the global. Bill 28645 with modifier 78 (unplanned return for a related procedure during the postoperative period). Modifier 79 is incorrect here — reserve 79 for unrelated procedures.

06Does 28636 require prior authorization for Medicare?

Medicare does not require prior authorization for 28636 under the current Prior Authorization Program, which targets specific elective surgeries. Commercial and Medicaid payers vary; confirm with the specific plan, especially for non-traumatic dislocation presentations.

Sources & references

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

01CMS Physician Fee Schedule 2026
02
cms.gov
https://www.cms.gov/medicare/coding-billing/national-correct-coding-initiative-ncci-edits
03
abos.org
https://www.abos.org/wp-content/uploads/2019/12/sports-cpt-updated.pdf
04
aaos.org
https://www.aaos.org/quality/coding-and-reimbursement/

Mira AI Scribe

Mira's AI scribe captures the joint level (which MTP joint), the manipulation technique, the percutaneous fixation details (wire type, number, placement approach), laterality, and fluoroscopic confirmation from the operative dictation. This prevents the most common 28636 denial: a note that documents reduction but omits explicit confirmation that percutaneous hardware was placed — which forces a downcode to 28630.

See how Mira captures CPT 28636 documentation