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The procedure described by CPT® Code 28210 involves the surgical repair of an extensor tendon in the foot using a secondary graft. Extensor tendons are crucial for the movement of the toes and foot, and they include several key muscles such as the tibialis anterior, extensor digitorum, peroneus tertius, and extensor hallucis longus. 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. In this procedure, a surgical incision is made over the site of the tendon injury to access the damaged tendon. 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 repairs the damaged fibers directly. If the muscle itself is injured, it is repaired in layers to restore function. For cases requiring a graft, a tendon graft is harvested from another site and attached to the remaining tendon ends, ensuring proper alignment and tension to facilitate movement. The procedure concludes with the closure of the surgical wound in layers and immobilization of the affected area using a splint or cast to promote healing.
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The procedure is indicated for the following conditions:
The surgical procedure begins with the identification of the injury site, where an incision is made over the extensor tendon or muscle that has sustained damage. If the extensor tendon is completely transected, the surgeon carefully locates the severed ends of the tendon. These ends are then grasped and pulled either distally or proximally to align them for repair. The surgeon proceeds to suture the tendon ends together to restore continuity. In cases where the tendon is only partially transected, the surgeon repairs the transected fibers directly to ensure proper function. If there is damage to the muscle itself, the muscle tissue is meticulously repaired in layers to promote healing and restore strength. For secondary graft repairs, a tendon graft is harvested from a donor site, which may be from the patient’s own body. This graft is then attached to the remnants of the severed tendon in the lower leg. The distal insertion site of the tendon is also secured to the graft. After the graft is in place, the surgeon tests the range of motion and adjusts the tension as necessary to ensure optimal movement of the foot and toes. Finally, the surgical wound is closed in layers to promote healing, and the lower leg, ankle, and foot are immobilized using a splint or cast to support recovery.
Post-procedure care involves monitoring the surgical site for signs of infection and ensuring that the immobilization device remains intact. Patients are typically advised to keep the affected area elevated to reduce swelling and to follow specific instructions regarding weight-bearing activities. Rehabilitation may include physical therapy to restore range of motion and strength in the foot and toes as healing progresses. Follow-up appointments are essential to assess the healing process and to make any necessary adjustments to the treatment plan.
| Short Descr | REPAIR/GRAFT OF FOOT TENDON | Medium Descr | RPR TENDON XTNSR FOOT SEC W/FREE GRAFT EA TENDON | Long Descr | Repair, tendon, extensor, 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) | 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 | 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). | 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.) | 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 | 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) | SG | Ambulatory surgical center (asc) facility service | T1 | Left foot, second digit | T2 | Left foot, third digit | T4 | Left foot, fifth digit | T6 | Right foot, second digit | 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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| Pre-1990 | Added | Code added. |
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