Open surgical treatment of a metatarsophalangeal joint dislocation, with internal fixation applied when clinically necessary.

Verified May 8, 2026 · 8 sources ↓

Medicare: $666.35
Work RVU: 7.25
Global, days: 90
Region: Foot & ankle

Drawn from CMSCgsmedicareAAOSMdclarityPayerprice

Documentation requirements

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

Source · Editorial brief grounded in 8 cited references ↓

Identify the specific MTP joint(s) treated, including toe number and laterality (left/right).
Document whether internal fixation was applied and specify the type and placement of hardware used.
Describe the surgical approach and technique used to achieve reduction of the dislocation.
Record pre-operative imaging (X-ray or other) confirming the dislocation and post-reduction imaging confirming alignment.
If multiple MTP joints were treated, document each joint separately in the operative note with distinct findings and interventions.
If billing 28285 or 28308 at the same session, document that the additional procedure was performed at a distinct anatomical site with separate clinical indication.

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 50 Bilateral procedure 51 Multiple procedures 58 Staged or related 59 Distinct service 76 Repeat, same physician 78 Unplanned return — related 79 Unrelated during global LT Left side RT Right side

What this code covers

Source · Editorial summary grounded in 8 cited references ↓

CPT 28645 covers open reduction of a dislocated metatarsophalangeal (MTP) joint, including internal fixation when the surgeon determines stabilization is required. The procedure involves surgical exposure of the affected MTP joint, manual or instrument-assisted reduction of the dislocation, and — where joint stability cannot be maintained by position alone — placement of internal fixation hardware such as K-wires or screws. The 90-day global period means all routine post-op care through day 90 is bundled; unrelated E/M visits in that window require modifier 24.

When multiple MTP joints are treated at the same operative session, each dislocated joint is reported separately with modifier 51 on the secondary code(s). NCCI PTP edits bundle 28285 (hammertoe repair) and 28308 (osteotomy, metatarsal) into 28645 — if those procedures are performed at a distinct site or represent a clinically separate service, append modifier 59 and ensure the operative note supports separate reporting. Capsulotomies performed as part of the dislocation exposure are bundled and not separately billable.

The procedure is performed almost exclusively in an ASC or hospital outpatient setting. Site of service matters for reimbursement — see the Site of Service comparison table on this page. Laterality modifiers LT and RT are expected when billing for a single-side procedure, and some payers require them to process the claim cleanly.

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 (7.25) is the surgeon's own effort — the figure physician pay and productivity targets are built on. The total RVU (19.95) adds practice overhead and malpractice, and is what drives the Medicare payment below.

Work RVU	7.25
Practice expense RVU	11.8
Malpractice RVU	0.9
Total RVU	19.95
Medicare national rate	$666.35
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	$666.35
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 28645 get rejected.

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

Missing or insufficient laterality — payers expect LT or RT; claims without laterality modifiers are frequently rejected.
NCCI bundling denial when 28285 or 28308 is billed same-day without modifier 59 and supporting documentation of a distinct service.
Lack of pre-operative imaging in the record to substantiate an open reduction versus a closed manipulation.
Global period conflicts — post-op E/M visits billed without modifier 24 when unrelated to the surgical diagnosis are denied as bundled.
Upcoding flag when multiple units are billed without separate operative note entries for each MTP joint addressed.

Frequently asked questions

Source · Generated from the editorial pipeline, verified against 8 cited references ↓

01Can I bill 28645 for each dislocated MTP joint treated at the same session?

Yes. Each MTP joint treated is a separately billable unit. Report 28645 for the primary joint, then append modifier 51 to each additional unit. The operative note must document distinct findings and intervention for every joint — a single generic note covering 'multiple MTP joints' is an audit target.

02Is internal fixation required to bill 28645?

No. The code describes open treatment with internal fixation 'when performed' — meaning fixation is included if done but not required to use the code. What drives code selection is the open surgical approach, not the presence of hardware.

0328285 (hammertoe repair) is bundled into 28645 per NCCI. Can I ever bill both?

Yes, if the hammertoe repair was performed on a different toe than the MTP dislocation and the procedures are clinically distinct. Append modifier 59 to 28285 and document the separate anatomical sites and indications in the operative note. A modifier indicator of 1 applies to this edit pair, so the modifier can override the bundle when documentation supports it.

04What modifier applies if the patient returns to the OR within the 90-day global for a related complication?

Use modifier 78 for an unplanned return to the OR for a procedure related to the original surgery within the global period. If the return procedure is unrelated to the MTP repair, use modifier 79 instead. Do not use modifier 58 — that is reserved for planned staged procedures.

05Does the 90-day global period cover hardware removal if the K-wire needs to come out?

Routine K-wire removal during the global period is bundled and not separately billable. If removal requires a separate anesthetic or unexpected complexity, modifier 22 on the removal code with supporting documentation is the path — though payer acceptance varies and some will still bundle it.

06When is modifier 22 appropriate for 28645?

Use modifier 22 when the procedure required substantially more work than typical — for example, a chronic dislocation with significant fibrosis, severe deformity requiring extensive dissection, or an unusually complex fixation construct. Attach an operative note excerpt that quantifies the extra time and work; without it, the modifier is typically rejected.

Sources & references

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

Mira Scribe

Mira's AI scribe captures the specific MTP joint number, laterality, reduction technique, and whether internal fixation was placed — pulling those details directly from surgeon dictation. It also flags when 28285 or 28308 appears in the same operative note, prompting a modifier 59 review before the claim is submitted. That prevents the two most common denials on this code: missing laterality and NCCI bundling rejections.

See how Mira captures CPT 28645 documentation