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The procedure described by CPT® Code 28202 involves the repair of a flexor tendon in the foot using a secondary graft. Flexor tendons are crucial for the movement of the toes and foot, and they include several muscles such as the peroneus longus, peroneus brevis, plantaris, popliteus, flexor digitorum longus, flexor hallucis longus, and tibialis posterior. Injuries to these tendons can occur due to various reasons, including lacerations, puncture wounds, or closed injuries like avulsions, which can lead to partial or complete transection of the tendons. During the procedure, an incision is made over the site of the tendon injury to access the affected area. If the tendon is completely severed, the surgeon locates the ends of the tendon, pulls them together, and repairs them with sutures. In cases of partial transection, the surgeon focuses on repairing the damaged fibers. If the muscle itself is involved, it is repaired in layers to restore its function. For cases requiring a graft, a tendon graft is harvested from another site and attached to the remaining tendon tissue. This graft is then secured at the distal insertion point of the tendon to ensure proper function. After the repair, the range of motion is assessed, and adjustments are made to ensure optimal movement of the foot and toes. Finally, the surgical site is closed in layers, and the lower leg, ankle, and foot are immobilized with a splint or cast to promote healing.
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The procedure is indicated for the following conditions:
The procedure consists of several key steps that ensure the effective repair of the flexor tendon:
Post-procedure care involves monitoring the surgical site for signs of infection and ensuring that the immobilization device remains intact. Patients are typically advised on how to manage pain and swelling, and follow-up appointments are scheduled to assess healing progress. Rehabilitation may be necessary to restore full function and strength to the foot and toes, which may include physical therapy and gradual reintroduction of movement as healing allows.
| Short Descr | REPAIR/GRAFT OF FOOT TENDON | Medium Descr | RPR TENDON FLXR FOOT SEC W/FREE GRAFT EA TENDON | Long Descr | Repair, tendon, flexor, foot; secondary with free graft, each tendon (includes obtaining graft) | 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) | 2 - Payment restriction for assistants at surgery does not apply to this procedure... | Co-Surgeons (62) | 1 - Co-surgeons could be paid, though supporting documentation is required... | 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 | 2 | 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). | RT | Right side (used to identify procedures performed on the right side of the body) | 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. | 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. | 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.) | 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 | F6 | Right hand, second digit | 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) | SG | Ambulatory surgical center (asc) facility service | T1 | Left foot, second digit | T2 | Left foot, third digit | T6 | Right foot, second digit | T9 | Right foot, fifth digit | XS | Separate structure, a service that is distinct because it was performed on a separate organ/structure |
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| Pre-1990 | Added | Code added. |
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