How To Use CPT Code 26416

CPT 26416 describes the removal of a synthetic rod and the insertion of an extensor tendon graft in the hand or finger. This article will cover the description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples.

1. What is CPT Code 26416?

CPT 26416 is used to describe the procedure in which a provider removes a synthetic rod that was previously placed in a patient’s hand or finger and replaces it with an extensor tendon graft. This code should be reported for each rod that is removed and replaced with a tendon graft.

2. Official Description

The official description of CPT code 26416 is: ‘Removal of synthetic rod and insertion of extensor tendon graft (includes obtaining graft), hand or finger, each rod.’

3. Procedure

1. The provider incises the skin over the synthetic rod that was previously placed in the patient’s hand or finger.
2. The provider removes the synthetic rod and creates a site for the extensor tendon graft.
3. An extensor tendon graft is harvested from the patient’s foot or a tendon of the palmaris longus muscle in the forearm.
4. The provider sutures the extensor tendon graft into place, stops any bleeding, and closes the site with sutures.

4. Qualifying circumstances

CPT 26416 is performed when a patient has a torn or defected extensor tendon in their hand or finger. The procedure is necessary to restore proper hand or finger movement and alleviate symptoms such as swelling and pain. The patient must have a synthetic rod previously placed in their hand or finger, which is then removed and replaced with an extensor tendon graft.

5. When to use CPT code 26416

CPT code 26416 should be used when a provider performs the removal of a synthetic rod and the insertion of an extensor tendon graft in the hand or finger. This code should be reported for each rod that is removed and replaced with a tendon graft.

6. Documentation requirements

To support a claim for CPT 26416, the provider must document the following information:

• Patient’s diagnosis and the need for the removal of the synthetic rod and insertion of an extensor tendon graft
• Details of the procedure, including the incision, removal of the synthetic rod, and suturing of the extensor tendon graft
• Documentation of any complications or additional procedures performed
• Signature of the provider performing the procedure

7. Billing guidelines

When billing for CPT 26416, ensure that the procedure involves the removal of a synthetic rod and the insertion of an extensor tendon graft in the hand or finger. Report this code for each rod that is removed and replaced with a tendon graft. It is important to follow any specific guidelines provided by the payer regarding the use of modifiers or additional documentation requirements.

8. Historical information

CPT 26416 was added to the Current Procedural Terminology system on January 1, 1990. There have been no updates or changes to the code since its addition.

9. Examples

1. A provider removes a synthetic rod from a patient’s finger and replaces it with an extensor tendon graft.
2. A patient undergoes the removal of a synthetic rod from their hand and the insertion of an extensor tendon graft.
3. A provider performs the removal and replacement of a synthetic rod with an extensor tendon graft in a patient’s finger.
4. An extensor tendon graft is inserted in a patient’s hand after the removal of a synthetic rod.
5. A provider removes a synthetic rod from a patient’s finger and sutures an extensor tendon graft into place.
6. A patient undergoes the removal of a synthetic rod from their hand and the insertion of an extensor tendon graft harvested from their foot.
7. A provider performs the removal and replacement of a synthetic rod with an extensor tendon graft in a patient’s finger, using an operating microscope.
8. An extensor tendon graft is inserted in a patient’s hand after the removal of a synthetic rod, with the use of an operating microscope.
9. A provider removes a synthetic rod from a patient’s finger and sutures an extensor tendon graft into place, including the repair of the donor site.
10. A patient undergoes the removal of a synthetic rod from their hand and the insertion of an extensor tendon graft harvested from their foot, including the repair of the donor site and the use of a tendon transfer.