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The procedure described by CPT® Code 28234 refers to an open tenotomy of the extensor tendon in the foot or toe. A tenotomy is a surgical procedure that involves the cutting of a tendon, which is a fibrous connective tissue that attaches muscle to bone. In this specific case, the extensor tendon, which is responsible for extending the toes and lifting the foot, is targeted. The procedure begins with making an incision in the skin directly over the extensor tendon that requires intervention. This incision allows the surgeon to access the underlying soft tissues, which are carefully dissected to expose the tendon. Once the tendon is visible, it is incised, severed, or released as necessary to alleviate tension or correct deformities. To manage any bleeding that may occur during the procedure, electrocautery is utilized, which is a technique that uses electrical current to coagulate blood vessels. After the tendon has been addressed, the surgical site is meticulously closed in layers to promote proper healing. It is important to report CPT® Code 28234 for each extensor tendon that is subjected to this tenotomy procedure in the foot or toe.
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The indications for performing an open tenotomy of the extensor tendon in the foot or toe, as described by CPT® Code 28234, typically include conditions that necessitate the release or severing of the tendon to alleviate pain, correct deformities, or improve function. These may include:
The procedure for an open tenotomy of the extensor tendon involves several critical steps, which are outlined as follows:
After the completion of the open tenotomy procedure, patients can expect specific post-operative care and recovery considerations. It is essential to monitor the surgical site for any signs of infection or complications. Patients may be advised to keep the foot elevated to reduce swelling and to follow specific instructions regarding weight-bearing activities. Pain management may be necessary, and the use of prescribed medications should be adhered to. Follow-up appointments will be scheduled to assess healing and to determine if any additional interventions are required. Rehabilitation exercises may also be recommended to restore function and strength to the affected area as healing progresses.
| Short Descr | INCISION OF FOOT TENDON | Medium Descr | TENOTOMY OPEN EXTENSOR FOOT/TOE EACH TENDON | Long Descr | Tenotomy, open, extensor, foot or toe, each tendon | 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 | 6 | CCS Clinical Classification | 160 - Other therapeutic procedures on muscles and tendons |
| LT | Left side (used to identify procedures performed on the left side of the body) | 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). | 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. | RT | Right side (used to identify procedures performed on the right side of the body) | T6 | Right foot, second digit | T1 | Left foot, second 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.) | T3 | Left foot, fourth digit | T7 | Right foot, third digit | T2 | Left foot, third digit | 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). | 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 | ET | Emergency services | F1 | Left hand, second digit | F3 | Left hand, fourth digit | F4 | Left hand, fifth 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 | KX | Requirements specified in the medical policy have been met | SG | Ambulatory surgical center (asc) facility service | T4 | Left foot, fifth digit | T5 | Right foot, great toe | T8 | Right foot, fourth digit | T9 | Right foot, fifth digit | TA | Left foot, great toe | XE | Separate encounter, a service that is distinct because it occurred during a separate encounter | 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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