Digit or Toe Amputation
2882028825wRVU: 3.32 — Amputation, toe, at interphalangeal joint (3.32 wRVU, 0-day global) — joint disarticulation, not bone-level transection28810wRVU: 6.47 — Amputation, toe with metatarsal, single ray (6.47 wRVU, 90-day global)28111wRVU: 5.02 — Ostectomy, complete excision, first metatarsal head only (5.02 wRVU, 90-day global) — use 28112 for 2nd/3rd/4th, 28113 for 5th28112wRVU: 4.51 — Ostectomy, complete excision, 2nd/3rd/4th metatarsal head (4.51 wRVU, 90-day global)28113wRVU: 5.96 — Ostectomy, complete excision, 5th metatarsal head (5.96 wRVU, 90-day global)28153wRVU: 3.71 — Resection, condyle or distal phalanx, toe (3.71 wRVU)
[Diabetic foot infection / osteomyelitis / gangrene / trauma], [right / left] [great / second / third / fourth / fifth] toe
Same
[Disarticulation / amputation] of [right / left] [great / second / third / fourth / fifth] toe at [metatarsophalangeal joint / proximal phalanx]
[***, MD/DO]
[Resident/PA name]
[General / spinal / ankle block / local with sedation]
Patient presents with [gangrenous / infected / ischemic] [right / left] [great / second] toe in the setting of [diabetes mellitus / peripheral arterial disease / osteomyelitis / crush injury]. [Vascular surgery consulted; revascularization not an option / wound care failed to heal / bone biopsy confirmed osteomyelitis.] Ankle-brachial index [X]. Risks including wound dehiscence, proximal spread of infection, re-amputation at higher level, and perioperative complications discussed with patient and family. Consent obtained.
[Gangrenous / infected / ischemic] changes affecting [toe / metatarsal head]. [Bone exposed / purulence noted / surrounding cellulitis.] [Metatarsal head viable / metatarsal head involved and resected.] [Intraoperative bone biopsy sent / cultures sent.]
The patient was positioned supine with the operative extremity prepped and draped in sterile fashion. [A thigh tourniquet was inflated to [X] mmHg / No tourniquet used given vascular compromise.]
A [racquet / fish-mouth / longitudinal] incision was planned at the [metatarsophalangeal joint level / base of the proximal phalanx]. The skin and soft tissues were incised and the flaps reflected. The extensor and flexor tendons were drawn distally, divided, and allowed to retract. The digital nerves were identified and divided sharply proximal to the level of bone transection so the cut ends retract away from the stump, and the digital vessels were divided and ligated. The toe was [disarticulated at the MTP joint / amputated through the proximal phalanx (bone transection, not disarticulation)] using a [oscillating saw / scalpel and rongeur]. [For a great-toe amputation, at least 1 cm of the base of the proximal phalanx was preserved rather than disarticulating at the MTP joint, maintaining the flexor hallucis brevis and plantar fascia attachments for weight-bearing.] Bone edges were smoothed to a bevel. [The metatarsal head was assessed: [viable and preserved / irregular and resected with rongeur to viable bleeding cortical bone].]
Intraoperative cultures were sent. The wound was irrigated copiously with [3 L / X L] normal saline. [Bone edges were smoothed with a rongeur.] [Primary closure performed with [2-0 Vicryl] for deep layer and [3-0 Nylon] for skin / Wound left open for secondary intention healing given contamination.] A [bulky / saline-soaked] dressing was applied.
[Tourniquet released. Hemostasis confirmed.] Patient tolerated the procedure well.
None
[Digit and/or bone sent to pathology and microbiology / Intraoperative bone cultures sent]
Minimal
None
Patient taken to PACU in stable condition. Admitted for postoperative wound care and antibiotics.
Epic SmartPhrase Version
PREOPERATIVE DIAGNOSIS: [Diabetic foot infection / gangrene / osteomyelitis], [right / left] [great / second / third] toe
POSTOPERATIVE DIAGNOSIS: Same
PROCEDURE PERFORMED: [Disarticulation / amputation] of [right / left] [great / second / third / fourth / fifth] toe at metatarsophalangeal joint
ATTENDING SURGEON: ***, MD/DO
FIRST ASSISTANT: ***
ANESTHESIA: [General / spinal / ankle block]
INDICATIONS: The patient is a .PTAGE-year-old .PTSEX with [gangrenous / infected / ischemic] changes of the [right / left] [great / second] toe in the setting of [diabetes mellitus / peripheral arterial disease / osteomyelitis]. [Vascular surgery evaluated; revascularization not feasible.] ABI: ***. Risks including wound dehiscence, proximal spread of infection, and need for re-amputation were discussed. Informed consent obtained.
FINDINGS: [Gangrenous / infected] changes to [toe / metatarsal head]. [Bone exposed / purulence present.] Metatarsal head [viable and preserved / involved and resected to viable bone]. Cultures sent.
DESCRIPTION OF PROCEDURE:
Patient supine; [right / left] extremity prepped and draped sterile. [Thigh tourniquet inflated to *** mmHg / No tourniquet; vascular compromise.] [Racquet / fish-mouth] incision at MTP joint level. Skin and soft tissues incised, flaps reflected; extensor and flexor tendons drawn distally, divided, and allowed to retract. Digital nerves identified and divided proximal to the bone-transection level; digital vessels divided and ligated. Toe [disarticulated at MTP joint / amputated through proximal phalanx] with [oscillating saw / scalpel and rongeur]. [Great toe: at least 1 cm of base of proximal phalanx preserved (retains flexor hallucis brevis and plantar fascia for weight-bearing).] Bone edges beveled. [Metatarsal head assessed: viable and preserved / resected to viable cortical bone.] Bone cultures and [tissue for pathology] sent. Wound irrigated with *** L normal saline. [Primary closure with 2-0 Vicryl deep layer and 3-0 Nylon skin / Left open given contamination.] Dressing applied. [Tourniquet released; hemostasis confirmed.] Patient tolerated the procedure well.
ESTIMATED BLOOD LOSS: Minimal
SPECIMENS: Digit and bone to pathology and microbiology
COMPLICATIONS: None
DRAINS: None
DISPOSITION: Patient to PACU in stable condition. Admitted for wound care and antibiotics.
Signed: .ME, .MYDEGREE
.TODAYVariants
Great toe amputation (preserve proximal phalanx base)
When the great toe must be amputated, preserve at least 1 cm of the base of the proximal phalanx rather than performing a full metatarsophalangeal disarticulation. This retains the insertion of the flexor hallucis brevis and the plantar fascia, preserving weight-bearing and balance and reducing transfer pressure and mal perforans ulceration, which is especially important in diabetic patients. Use a medial racquet or fish-mouth incision based on viable skin, transect the phalanx 1 cm from the base with an oscillating saw, and bevel the bone edges. Reserve MTP disarticulation for cases where proximal phalangeal bone is nonviable or infected.
Ray amputation
Includes partial or complete metatarsal resection with the toe. Document extent of metatarsal removed, closure technique, and whether adjacent weight-bearing is preserved. CPT 28810 (6.47 wRVU, 90-day global). For isolated metatarsal head resection without toe amputation, use 28111 (first metatarsal only), 28112 (2nd/3rd/4th), or 28113 (5th).
Transmetatarsal amputation (TMA)
For forefoot gangrene or multilevel toe involvement. CPT 28805 (12.39 wRVU, 90-day global). Document level of bone transection, beveling for weight distribution, and closure with plantar flap.
Finger disarticulation (hand)
CPT 26951 (5.89 wRVU, 90-day global) covers amputation at any joint OR through any phalanx with direct closure — not limited to PIP/DIP disarticulation. CPT 26952 (6.32 wRVU) is the same procedure with local advancement flap (V-Y or hood flap). CPT 26910 (7.60 wRVU) is ray amputation — metacarpal with digit. Document digital nerve transaction level and tendon management.
Charting Tips
- Document exact amputation level (metatarsophalangeal joint, proximal/mid/distal phalanx)
- For the great toe, document whether the base of the proximal phalanx was preserved (at least 1 cm) or a full MTP disarticulation was performed. Preserving the phalangeal base retains the flexor hallucis brevis and plantar fascia attachments and weight-bearing function
- Document that the digital nerves were divided proximal to the level of bone transection so the cut ends retract away from the weight-bearing stump, reducing symptomatic neuroma
- State tourniquet use (or explain why not used in vascular patients)
- Note metatarsal head viability and whether it was preserved or resected
- Send bone for pathology and cultures separately when osteomyelitis is suspected
- Document wound closure method (primary vs. open) and rationale if left open
- Note vascular assessment preoperatively. ABI is unreliable in diabetics with calcified vessels (falsely elevated). Toe pressures, TcPO2, or SPP are preferred when ABI is >1.3 or wound healing is questionable. Document which modality was used and the result.
- Medicare claims for 28820, 28825, and 28810 require HCPCS T-modifiers identifying the specific toe (TA = left great; T1–T4 = left 2nd–5th; T5 = right great; T6–T9 = right 2nd–5th). Failure to append the T-modifier is a common denial cause.
Billing Tips
- Select code by amputation level: 28820 (MTP joint disarticulation, 3.42 wRVU, 0-day global); 28825 (amputation at the interphalangeal joint, 3.32 wRVU, 0-day global — NOT 'proximal phalanx'; this is a joint disarticulation); 28810 (ray amputation — toe with metatarsal, 6.47 wRVU, 90-day global); 28800 (Chopart/midfoot, 8.57 wRVU, 90-day global); 28805 (transmetatarsal, 12.39 wRVU, 90-day global).
- Ray amputation (toe with metatarsal) uses 28810 (6.47 wRVU, 90-day global). For isolated metatarsal head resection without toe amputation: 28111 (FIRST metatarsal head only, 5.02 wRVU), 28112 (2nd/3rd/4th metatarsal head, 4.51 wRVU), or 28113 (5th metatarsal head, 5.96 wRVU). Diabetic forefoot cases commonly involve 2nd–5th metatarsals — do not use 28111 for non-first metatarsal resections.
- Global period: 28820 and 28825 have a 0-day global (changed from 90-day effective January 2021). 28810, 28800, and 28805 retain 90-day global periods. With a 0-day global, routine postoperative E/M visits are billed normally without global-period modifiers. Modifiers -24 and -79 apply within 90-day global periods, not 0-day globals.
- Medicare requires HCPCS T-modifiers to identify the specific toe: TA = left great toe; T1–T4 = left 2nd–5th toes; T5 = right great toe; T6–T9 = right 2nd–5th toes. Claims for 28820, 28825, and 28810 are frequently denied without the correct T-modifier.
- For finger amputations (hand surgery): 26951 (amputation at any joint or phalanx, direct closure, 5.89 wRVU, 90-day global) or 26952 (same with local advancement flap, 6.32 wRVU); 26910 (ray amputation — metacarpal + finger, 7.60 wRVU). Do not mix hand and foot codes.
General coding reference. Verify with your institution’s billing department before submitting claims.