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The procedure described by CPT® Code 26416 involves the removal of a synthetic rod and the insertion of an extensor tendon graft in the hand or finger. This procedure is typically indicated when an extensor tendon repair has either failed or was not performed in a timely manner, necessitating a two-stage surgical approach to restore function. The first stage, which is coded under CPT® Code 26415, involves the excision of the injured tendon and the placement of a synthetic rod to facilitate healing. The second stage, represented by CPT® Code 26416, focuses on the actual grafting process. During this stage, a tendon graft is harvested from either the forearm or leg, and the previously placed synthetic rod is removed. As the rod is extracted, the tendon graft is pulled into the newly formed tendon sheath, allowing for proper alignment and attachment to the native tendon. This procedure is critical for patients who have experienced tendon injuries that require surgical intervention to restore hand or finger function.
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The procedure coded as CPT® 26416 is indicated for patients who have experienced a failure of extensor tendon repair or have not undergone timely repair of the extensor tendon. This situation may arise due to various factors, including trauma, chronic conditions, or complications from previous surgical interventions. The need for a two-stage procedure is essential to ensure proper healing and restoration of function in the hand or finger.
The procedure involves several critical steps to ensure successful tendon grafting. Each step is designed to facilitate the removal of the synthetic rod and the insertion of the tendon graft.
After the completion of the procedure, patients can expect a recovery period that may involve immobilization of the hand or finger to allow for proper healing of the tendon graft. Follow-up appointments will be necessary to monitor the healing process and assess the function of the tendon. Rehabilitation may include physical therapy to restore strength and range of motion as the graft integrates with the surrounding tissues. It is important for patients to adhere to post-operative care instructions to optimize recovery outcomes.
| Short Descr | GRAFT HAND OR FINGER TENDON | Medium Descr | RMVL SYNTH ROD & INSJ XTNSR TDN GRF H/F EA ROD | Long Descr | Removal of synthetic rod and insertion of extensor tendon graft (includes obtaining 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) | 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) | 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). | 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. | F2 | Left hand, third digit | F3 | Left hand, fourth digit | F7 | Right hand, third digit | F8 | Right hand, fourth digit | F9 | Right hand, fifth digit | LT | Left side (used to identify procedures performed on the left side of the body) | XS | Separate structure, a service that is distinct because it was performed on a separate organ/structure |
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| 2013-01-01 | Changed | Medium Descriptor changed. |
| 2002-01-01 | Changed | Code description changed. |
| Pre-1990 | Added | Code added. |
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