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2025 CPT code 26428

Repair of extensor tendon, central slip, secondary (e.g., boutonniere deformity); with free graft (includes obtaining graft).

This code is reported per finger. If the same procedure is performed on multiple fingers, the code should be reported multiple times with the appropriate modifier (e.g., -F1 for the left hand, second digit).

Modifiers may be applicable, such as those for specifying laterality (-LT, -RT), anatomical location specific to digits (-F1 through -F9), or unusual circumstances (e.g., -22 for increased procedural services).

Medical necessity for this procedure must be clearly documented. This includes functional limitations caused by the deformity, failed conservative treatment attempts, and the expected improvement in function with surgical intervention. The documentation must support the need for a free graft rather than a simpler repair.

The surgeon is responsible for the entire procedure, starting from prepping and anesthetizing the patient, making the incisions, harvesting the graft, repairing the tendon, closing the incisions, and managing any complications.

In simple words: This procedure repairs a damaged tendon in your finger that helps you straighten it. Because it's a second attempt to fix the tendon, the surgeon will use a piece of tissue from another part of your body as a graft to rebuild the tendon.

This code describes a surgical procedure to repair a damaged extensor tendon in the finger, specifically the central slip, which is crucial for extending the proximal interphalangeal (PIP) joint. This is a secondary repair, meaning it's not the initial treatment of the injury. The procedure involves using a free graft (tissue taken from another part of the patient's body) to reconstruct the tendon. The harvesting of the graft is included in this code.

Example 1: A patient previously had a boutonniere deformity repair that failed. They now require a secondary repair with a free graft to restore function to the finger., A patient with a ruptured central slip extensor tendon has a secondary repair with a free graft due to significant scarring and tissue loss from the initial injury., A patient has a chronic boutonniere deformity with significant retraction of the central slip. A secondary repair with a tendon graft is necessary to lengthen the tendon and restore joint function.

Documentation should include details of the original injury, previous treatments, the location and severity of the boutonniere deformity, the source of the graft, the surgical technique used, and any complications encountered. Operative reports, pre- and post-operative images, and physical therapy notes are essential.

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