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Tenolysis is a surgical procedure aimed at freeing a tendon from the surrounding tissue that may be restricting its movement. Specifically, CPT® Code 28226 refers to the tenolysis of multiple extensor tendons in the foot. This procedure is typically indicated when scar tissue has formed around the tendons due to trauma or a disease process, which can impede the normal motion of the foot and toes. The goal of tenolysis is to restore the range of motion by carefully releasing these adhesions. During the procedure, an incision is made over the affected tendons, and the surrounding soft tissues are meticulously dissected to expose the tendons. Once identified, the adhesions that bind the tendons to the surrounding structures are severed. After the tendons are freed, the range of motion is assessed to ensure that the procedure has been successful. The surgical site is then closed in layers, and a dressing is applied to protect the area as it heals. This procedure is essential for patients who have experienced significant limitations in foot and toe movement due to tendon adhesions.
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The procedure described by CPT® Code 28226 is indicated for patients who have developed restrictions in the movement of their foot and/or toes due to the formation of scar tissue around multiple extensor tendons. This condition may arise from various factors, including:
The tenolysis procedure for multiple extensor tendons, as outlined in CPT® Code 28226, involves several key steps to ensure the successful release of the tendons. Each step is critical for achieving the desired outcome of restoring motion to the affected area.
After the tenolysis procedure, patients are typically monitored for any immediate complications. Post-operative care may include instructions for wound care, pain management, and activity restrictions to promote healing. Patients may be advised to engage in physical therapy to regain strength and improve the range of motion in the foot and toes. Follow-up appointments are essential to assess the healing process and to ensure that the tendons are functioning properly. The expected recovery time can vary based on the extent of the procedure and the individual patient's healing response.
| Short Descr | RELEASE OF FOOT TENDONS | Medium Descr | TENOLYSIS EXTENSOR FOOT MULTIPLE TENDON | Long Descr | Tenolysis, extensor, foot; 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) | 1 - 150% payment adjustment for bilateral procedures applies. | 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 | 1 | 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.) | 99 | Multiple modifiers: under certain circumstances 2 or more modifiers may be necessary to completely delineate a service. in such situations modifier 99 should be added to the basic procedure, and other applicable modifiers may be listed as part of the description of the service. | 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) | T1 | Left foot, second digit | T2 | Left foot, third digit | T4 | Left foot, fifth digit | T5 | Right foot, great toe | T6 | Right foot, second digit | T7 | Right foot, third digit | T8 | Right foot, fourth digit | T9 | Right foot, fifth digit | TA | Left foot, great toe | 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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