06/19/2017

CPT Code for Posterior Tibial Tendon Tear (Partial)

What is the correct CPT code for a posterior tibial tendon tear (partial). Thank you!

The correct CPT code is 28200

Code Description:

28200 -Repair, tendon, flexor, foot; primary or secondary, without free graft, each tendon

Lay Description (Code)

If the tendon has ruptured, surgery may be required to repair the ruptured tendon or to replace it with a tendon graft. Usually, another tendon in the foot, such as the tendon that bends the four lesser toes is used as a tendon graft to replace the function of the posterior tibial tendon. In cases of a fixed flatfoot, the physician may perform a fusion (or arthrodesis) of the foot that requires the removal of a joint between two bones and the two bones on either side of the joint are allowed to grow together. This type of operation is used to stop pain from joints or to realign the bones. Several joints must be fused to control the flatfoot after a posterior tibial tendon rupture. Report 28202 if a free graft is used for the repair. The patient may be placed in a cast for six to eight weeks.

Coding Tips

Procedures 28200 and 28202 may be reported multiple times as these codes should be reported for each flexor tendon repair. When 28200 or 28202 is performed with another separately identifiable procedure, the highest dollar value code is listed as the primary procedure and subsequent procedures are appended with modifier 51. Harvesting of free tendon graft is included in 28202 and should not be reported separately.