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The procedure described by CPT® Code 26415 involves the excision of an extensor tendon in the hand or finger, accompanied by the implantation of a synthetic rod. This procedure is typically indicated when an extensor tendon repair has either failed or has not been performed in a timely manner, necessitating a delayed tendon grafting approach. The process is executed in two stages, with the first stage being the focus of this code. During this initial stage, a zigzag incision is made over the affected tendon to access the injured area. Careful dissection of the surrounding soft tissues is performed to protect vital neurovascular structures. The tendon sheath is then incised, allowing for the dissection and excision of the injured tendon. Following the removal of the damaged tendon, a synthetic rod is inserted along the entire length of the tendon sheath. This rod serves as a temporary support structure while the tendon sheath heals around it. After the synthetic rod is placed, the overlying soft tissues and skin are meticulously closed in layers. The synthetic rod is designed to remain in place for approximately 10 weeks, during which time the healing process occurs, preparing the site for the subsequent tendon grafting procedure, which is addressed under CPT® Code 26416.
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The procedure described by CPT® Code 26415 is indicated for the following conditions:
The procedure begins with the creation of a zigzag incision over the affected extensor tendon. This incision allows for optimal access to the injured area while minimizing scarring. Once the incision is made, the surgeon carefully dissects the surrounding soft tissues, taking special care to protect the neurovascular structures that may be present in the area. After the soft tissues are adequately mobilized, the tendon sheath is incised to expose the injured tendon. The surgeon then meticulously dissects the injured tendon free from the surrounding tissue, ensuring that all damaged portions are removed. Following the excision of the injured tendon, a synthetic rod is inserted into the tendon sheath. This rod is designed to span the entire length of the sheath, providing structural support during the healing process. Once the synthetic rod is in place, the surgeon closes the overlying soft tissues and skin in layers to promote optimal healing. The synthetic rod is intended to remain in situ for approximately 10 weeks, allowing the tendon sheath to heal around it before the second stage of the procedure, which involves the actual tendon grafting, is performed.
After the completion of the procedure, the patient is typically monitored for any signs of complications, such as infection or improper healing. The synthetic rod will remain in place for about 10 weeks, during which time the patient may be advised to limit movement of the affected hand or finger to facilitate healing. Follow-up appointments will be necessary to assess the healing process and to plan for the subsequent stage of the procedure, which involves the harvesting of a tendon graft and its attachment to the synthetic rod. Patients may also receive instructions on wound care and signs to watch for that may indicate complications. Rehabilitation and physical therapy may be recommended following the second stage of the procedure to restore function and range of motion in the affected area.
| Short Descr | EXCISION HAND/FINGER TENDON | Medium Descr | EXC XTNSR TDN W/IMPLTJ SYNTH ROD DLYD GRF H/F EA | Long Descr | Excision of extensor tendon, with implantation of synthetic rod for delayed tendon graft, hand or finger, each rod | 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) | 0 - 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) | P3D - Major procedure, orthopedic - other | 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. | 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.) | AS | Physician assistant, nurse practitioner, or clinical nurse specialist services for assistant at surgery | F1 | Left hand, second digit | F2 | Left hand, third digit | F3 | Left hand, fourth digit | F6 | Right hand, second digit | F7 | Right hand, third digit | F8 | Right hand, fourth digit | F9 | Right hand, fifth digit | FA | Left hand, thumb | 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) | 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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| 2011-01-01 | Changed | Short description changed. |
| 2002-01-01 | Changed | Code description changed. |
| Pre-1990 | Added | Code added. |
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