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Official Description

Excision or curettage of bone cyst or benign tumor, talus or calcaneus; with allograft

© Copyright 2025 American Medical Association. All rights reserved.

Common Language Description

The CPT® Code 28103 refers to the surgical procedure involving the excision or curettage of a bone cyst or benign tumor located in the talus or calcaneus, which are bones in the foot. A bone cyst is defined as a fluid-filled space within the bone, and it can manifest in various forms. The unicameral or simple bone cyst is a common type, characterized as a benign lesion. Another type, the aneurysmal bone cyst, is less common and consists of vascular tissue surrounding a blood-filled cystic lesion. Additionally, benign bone tumors can include giant cell tumors, chondromyxoid fibromas, and enchondromas. The procedure begins with an incision made over the lesion site in the talus or calcaneus, followed by dissection of the soft tissues to expose the lesion. If a cystic lesion is identified, the bone is incised to create a window, allowing for the aspiration of fluid, which is then sent for laboratory analysis. The lining of the cystic cavity is removed using a curette. In cases where benign tumors are present, the lesion is excised along with a margin of healthy bone. Following the excision or curettage, the defect created in the bone is filled with donor bone (allograft), which is sourced from a separate donor site, ensuring the structural integrity and healing of the affected area.

© Copyright 2025 Coding Ahead. All rights reserved.

1. Indications

The procedure described by CPT® Code 28103 is indicated for the treatment of specific conditions affecting the talus or calcaneus, particularly when dealing with bone cysts or benign tumors. The following are the explicit indications for performing this procedure:

  • Bone Cysts - The presence of a fluid-filled space within the bone, which may require intervention to alleviate symptoms or prevent complications.
  • Benign Tumors - The excision of benign lesions such as giant cell tumors, chondromyxoid fibromas, or enchondromas that may cause pain, discomfort, or structural issues in the foot.

2. Procedure

The procedure for CPT® Code 28103 involves several critical steps to ensure the effective treatment of the bone cyst or benign tumor. The following outlines the procedural steps:

  • Step 1: Incision and Exposure - The procedure begins with the surgeon making an incision in the skin directly over the site of the lesion located in the talus or calcaneus. This incision allows for access to the underlying bone and soft tissues. The surgeon carefully dissects the soft tissues to fully expose the lesion, ensuring that all surrounding structures are preserved as much as possible.
  • Step 2: Creation of Bone Window - If a cystic lesion is identified, the surgeon proceeds to incise the bone to create a window. This window provides access to the cystic cavity. The fluid within the cyst is aspirated and sent to the laboratory for analysis, which may be necessary for further diagnostic purposes.
  • Step 3: Curettage or Excision - A curette is then inserted through the created bone window to remove the lining of the cystic cavity completely. In cases where a benign tumor is present, the surgeon excises the tumor along with a margin of healthy bone to ensure complete removal and minimize the risk of recurrence.
  • Step 4: Packing the Defect - After the lesion has been adequately treated through curettage or excision, the resulting defect in the talus or calcaneus is packed with donor bone (allograft). This allograft is sourced from a separate donor site and is used to fill the void left by the removed lesion, promoting healing and structural support for the bone.

3. Post-Procedure

Post-procedure care following the excision or curettage of a bone cyst or benign tumor involves monitoring the surgical site for signs of infection and ensuring proper healing. Patients may be advised to limit weight-bearing activities on the affected foot to facilitate recovery. Follow-up appointments are typically scheduled to assess the healing process and to ensure that the allograft is integrating properly with the surrounding bone. Additional imaging studies may be required to evaluate the success of the procedure and to monitor for any potential complications.

Short Descr REMOVE/GRAFT FOOT LESION
Medium Descr EXC/CURETTAGE CYST/TUMOR TALUS/CALCANEUS ALGRFT
Long Descr Excision or curettage of bone cyst or benign tumor, talus or calcaneus; with allograft
Status Code Active Code
Global Days 090 - Major Surgery
PC/TC Indicator (26, TC) 0 - Physician Service Code
Multiple Procedures (51) 2 - Standard payment adjustment rules for multiple procedures apply.
Bilateral Surgery (50) 1 - 150% payment adjustment for bilateral procedures applies.
Physician Supervisions 09 - Concept does not apply.
Assistant Surgeon (80, 82) 2 - Payment restriction for assistants at surgery does not apply to this procedure...
Co-Surgeons (62) 0 - Co-surgeons not permitted for this procedure.
Team Surgery (66) 0 - Team surgeons not permitted for this procedure.
Diagnostic Imaging Family 99 - Concept Does Not Apply
APC Status Indicator Hospital Part B services paid through a comprehensive APC
ASC Payment Indicator Device-intensive procedure added to ASC list in CY 2008 or later; paid at adjusted rate.
Type of Service (TOS) 2 - Surgery
Berenson-Eggers TOS (BETOS) P5B - Ambulatory procedures - musculoskeletal
MUE 1
CCS Clinical Classification 161 - Other OR therapeutic procedures on bone
22 Increased procedural services: when the work required to provide a service is substantially greater than typically required, it may be identified by adding modifier 22 to the usual procedure code. documentation must support the substantial additional work and the reason for the additional work (ie, increased intensity, time, technical difficulty of procedure, severity of patient's condition, physical and mental effort required). note: this modifier should not be appended to an e/m service.
50 Bilateral procedure: unless otherwise identified in the listings, bilateral procedures that are performed at the same session, should be identified by adding modifier 50 to the appropriate 5 digit code. note: this modifier should not be appended to designated "add-on" codes (see appendix d).
51 Multiple procedures: when multiple procedures, other than e/m services, physical medicine and rehabilitation services or provision of supplies (eg, vaccines), are performed at the same session by the same individual, the primary procedure or service may be reported as listed. the additional procedure(s) or service(s) may be identified by appending modifier 51 to the additional procedure or service code(s). note: this modifier should not be appended to designated "add-on" codes (see appendix d).
58 Staged or related procedure or service by the same physician or other qualified health care professional during the postoperative period: it may be necessary to indicate that the performance of a procedure or service during the postoperative period was: (a) planned or anticipated (staged); (b) more extensive than the original procedure; or (c) for therapy following a surgical procedure. this circumstance may be reported by adding modifier 58 to the staged or related procedure. note: for treatment of a problem that requires a return to the operating/procedure room (eg, unanticipated clinical condition), see modifier 78.
59 Distinct procedural service: under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-e/m services performed on the same day. modifier 59 is used to identify procedures/services, other than e/m services, that are not normally reported together, but are appropriate under the circumstances. documentation must support a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual. however, when another already established modifier is appropriate it should be used rather than modifier 59. only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used. note: modifier 59 should not be appended to an e/m service. to report a separate and distinct e/m service with a non-e/m service performed on the same date, see modifier 25.
78 Unplanned return to the operating/procedure room by the same physician or other qualified health care professional following initial procedure for a related procedure during the postoperative period: it may be necessary to indicate that another procedure was performed during the postoperative period of the initial procedure (unplanned procedure following initial procedure). when this procedure is related to the first, and requires the use of an operating/procedure room, it may be reported by adding modifier 78 to the related procedure. (for repeat procedures, see modifier 76.)
80 Assistant surgeon: surgical assistant services may be identified by adding modifier 80 to the usual procedure number(s).
82 Assistant surgeon (when qualified resident surgeon not available): the unavailability of a qualified resident surgeon is a prerequisite for use of modifier 82 appended to the usual procedure code number(s).
AS Physician assistant, nurse practitioner, or clinical nurse specialist services for assistant at surgery
GC This service has been performed in part by a resident under the direction of a teaching physician
LT Left side (used to identify procedures performed on the left side of the body)
RT Right side (used to identify procedures performed on the right side of the body)
XS Separate structure, a service that is distinct because it was performed on a separate organ/structure
XU Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service
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