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The procedure described by CPT® Code 28011 refers to a percutaneous tenotomy of multiple tendons in the toe. A tenotomy is a surgical procedure that involves the cutting or severing of a tendon to relieve tension or to correct a deformity. In this specific case, the procedure is performed through a small stab incision made directly over the flexor or extensor tendons that are targeted for incision. This minimally invasive approach allows for the precise release of multiple tendons, which can be beneficial in treating conditions that affect the toe's range of motion. After the tendons are incised, the physician evaluates the range of motion to assess the effectiveness of the procedure. The small incision is then typically closed using sutures or Steri-Strips, ensuring minimal scarring and promoting quicker recovery. It is important to note that CPT® Code 28010 is designated for the tenotomy of a single tendon, while CPT® Code 28011 is specifically used for cases involving multiple tendons.
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The procedure of percutaneous tenotomy of multiple tendons in the toe, as described by CPT® Code 28011, is indicated for various conditions that may impair the function or range of motion of the toe. These indications may include:
The procedure for a percutaneous tenotomy of multiple tendons in the toe involves several key steps, which are outlined as follows:
Following the percutaneous tenotomy of multiple tendons in the toe, patients can expect specific post-procedure care and considerations. It is important to monitor the incision site for any signs of infection or complications. Patients may be advised to keep the area clean and dry, and to follow any specific instructions provided by the healthcare provider regarding activity restrictions. Pain management may be necessary, and the physician may recommend over-the-counter pain relief or prescribe medication as needed. Rehabilitation exercises may also be introduced to help restore strength and flexibility in the toe as healing progresses. The expected recovery time can vary based on individual circumstances, but patients should be informed about the importance of follow-up appointments to assess healing and functional recovery.
| Short Descr | INCISION OF TOE TENDONS | Medium Descr | TENOTOMY PERCUTANEOUS TOE MULTIPLE TENDON | Long Descr | Tenotomy, percutaneous, toe; multiple tendons | 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) | 0 - 150% payment adjustment for bilateral procedures does NOT apply. | Physician Supervisions | 09 - Concept does not apply. | Assistant Surgeon (80, 82) | 1 - Statutory payment restriction for assistants at surgery applies 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 | Surgical procedure on ASC list in CY 2007; payment based on OPPS relative payment weight. | Type of Service (TOS) | 2 - Surgery | Berenson-Eggers TOS (BETOS) | P5B - Ambulatory procedures - musculoskeletal | MUE | 4 | CCS Clinical Classification | 160 - Other therapeutic procedures on muscles and tendons |
| 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). | T6 | Right foot, second digit | RT | Right side (used to identify procedures performed on the right side of the body) | 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. | T7 | Right foot, third digit | T9 | Right foot, fifth digit | 79 | Unrelated procedure or service by the same physician or other qualified health care professional during the postoperative period: the individual may need to indicate that the performance of a procedure or service during the postoperative period was unrelated to the original procedure. this circumstance may be reported by using modifier 79. (for repeat procedures on the same day, see modifier 76.) | T2 | Left foot, third digit | T3 | Left foot, fourth digit | T1 | Left foot, second digit | LT | Left side (used to identify procedures performed on the left side of the body) | T8 | Right foot, fourth digit | XS | Separate structure, a service that is distinct because it was performed on a separate organ/structure | 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. | 76 | Repeat procedure or service by same physician or other qualified health care professional: it may be necessary to indicate that a procedure or service was repeated by the same physician or other qualified health care professional subsequent to the original procedure or service. this circumstance may be reported by adding modifier 76 to the repeated procedure or service. note: this modifier should not be appended to an e/m service. | 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 | CR | Catastrophe/disaster related | ER | Items and services furnished by a provider-based, off-campus emergency department | F8 | Right hand, fourth digit | F9 | Right hand, fifth digit | GC | This service has been performed in part by a resident under the direction of a teaching physician | GW | Service not related to the hospice patient's terminal condition | SA | Nurse practitioner rendering service in collaboration with a physician | SG | Ambulatory surgical center (asc) facility service | T4 | Left foot, fifth digit | T5 | Right foot, great toe | TA | Left foot, great toe | 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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