You're staring at an operative report. The surgeon wrote "posterior tibial tendon repair" — maybe with a graft, maybe not. Maybe it was a primary repair. Maybe it was a revision. And now you're wondering: which CPT code actually fits?
Yeah. Been there.
The posterior tibial tendon is a workhorse. It holds up the medial arch. When it fails, the foot collapses. Surgery fixes it. But coding that surgery? That's where things get messy Worth knowing..
Let's sort it out Most people skip this — try not to..
What Is the Posterior Tibial Tendon Repair CPT Code
The primary code you'll use most often is 28200.
That's the CPT code for repair, tendon, flexor, foot; primary or secondary, without free graft, each tendon. Posterior tibial tendon falls under "flexor, foot." So 28200 covers a standard primary or secondary repair — no graft harvested from elsewhere Small thing, real impact..
But here's where it splits.
If the surgeon uses a free tendon graft — say, harvesting plantaris or using allograft — you're looking at 28202: repair, tendon, flexor, foot; with free graft (includes obtaining graft), each tendon Surprisingly effective..
And if they're doing a tendon transfer instead of a direct repair? Consider this: that's a different conversation entirely. We'll get there.
Primary vs secondary — does it matter for coding?
Not for 28200 or 28202. A secondary repair usually means more scar tissue, longer OR time, maybe a graft. Practically speaking, both codes say "primary or secondary. But your documentation better. " CPT doesn't distinguish. Now, that supports 28202 if a graft is used. If not, it's still 28200 — but the op note should reflect the complexity That's the whole idea..
Don't assume. Read the note.
Why This Code Trips People Up
Most coders don't mess up the base code. They mess up the modifiers, the bundling, and the clinical context.
Let's start with laterality. Always. You need RT or LT. Because of that, or 28200-50 if the payer accepts bilateral modifiers. And if the surgeon repaired both posterior tibial tendons in the same session — rare, but it happens — you'd bill 28200-RT and 28200-LT. So medicare and most payers will deny without it. Check your MAC.
Then there's the graft question.
Surgeons love to write "tendon repair with augmentation.Consider this: " Sometimes that means a suture anchor. In practice, a biologic wrap doesn't count. In real terms, **That is not a free graft. Sometimes it means a graft. ** CPT defines "free graft" as tissue harvested from a separate site or obtained as allograft. Sometimes it means they wrapped the repair with extracellular matrix (like GraftJacket or AmnioFix). Code 28200.
I've seen coders bill 28202 because "they used graft material." Nope. Not unless the op note says free tendon graft harvested from X or allograft tendon used.
What about tendon transfers?
Ah. The classic pivot.
If the posterior tibial tendon is too far gone — ruptured, retracted, degenerated — the surgeon might transfer the flexor digitorum longus (FDL) to the navicular. Here's the thing — that's not a repair. That's a transfer.
CPT code: 27691 — transfer or transplant of single tendon (with muscle redirection or rerouting); deep (eg, anterior tibial, posterior tibial, peroneal tendon) But it adds up..
Note: 27691 includes the harvest and the transfer. You don't bill 28200 and 27691 for the same tendon. It's one or the other.
And if they do an FDL transfer plus a calcaneal osteotomy (like a medializing calcaneal osteotomy for stage 2 PTTD)? That's 27691 + 28300 (osteotomy, calcaneus). Both pay — if documented separately and medically necessary.
How It Works: Coding Step by Step
Let's walk through a real-world workflow. You've got the op note open. Here's your checklist.
1. Identify the procedure performed
Read the procedure section — not just the heading. Consider this: surgeons often list "PTT repair" in the header but describe an FDL transfer in the body. Trust the body.
Look for keywords:
- "Direct repair" → 28200 or 28202
- "Free tendon graft" / "allograft" / "harvested plantaris" → 28202
- "FDL transfer" / "tendon transfer to navicular" → 27691
- "Spring ligament repair" → separate code (28585? No — that's for fracture. Spring ligament repair is often unlisted, 29999, or bundled — more on that)
2. Check for grafts
If the note says "augmented with GraftJacket" or "wrapped with AmnioFix," that's not a free graft. Code 28200 Simple, but easy to overlook..
If it says "harvested plantaris tendon from contralateral leg" or "used Achilles allograft," that is a free graft. Code 28202 That's the whole idea..
And yes — harvesting the graft is included in 28202. Don't bill a separate harvest code.
3. Verify laterality
Right foot? Bilateral? Left foot? Think about it: rT. LT. 50 or RT/LT — know your payer.
4. Check for bundled procedures
This is where money gets left on the table — or denials happen.
Common combos with PTT repair:
- Calcaneal osteotomy (28300) — medializing, lateralizing, or Dwyer. Separate incision? On top of that, usually yes. So bill it. - Medial cuneiform osteotomy (28306) — Cotton osteotomy. Often done with PTT repair for forefoot varus. Bill it. In real terms, - Spring ligament repair — controversial. Some coders bill 28585 (repair of ligament, ankle). But spring ligament isn't ankle. Worth adding: others use 29999 (unlisted). Many bundle it. Read your payer policy.
- Gastrocnemius recession (27687) — if done for equinus. Separate incision? Usually. Bill it.
- Synovectomy — bundled. Don't bill separately. Because of that, - Tenolysis — bundled if same tendon. On top of that, if different tendon (e. g.Here's the thing — , FHL tenolysis), maybe billable with 59 modifier. Tread carefully.
5. Apply modifiers
- 59 or XS — separate structure, separate incision. Use when you have a distinct procedure not normally bundled.
- 51 — multiple procedures. Most payers auto-apply this on the second/third code. You don't always need to add it manually.
- 22 — increased procedural services. Rare. Only if documentation supports significantly more work (e.g., massive scarring, revision with graft, 3+ hours). Payers scrutinize this hard.
6. Match diagnosis codes
PTT dysfunction staging matters And it works..
- **M21.4
6. Match diagnosis codes
The CPT codes are only part of the story. The ICD‑10‑CM codes you attach must reflect the exact pathology and severity; otherwise, the claim is likely to be denied or reduced.
Below is a quick reference for the most common PTT‑related diagnoses that should accompany the procedural codes Simple as that..
| ICD‑10‑CM | Foot/Ankle Condition | Typical Coding Context |
|---|---|---|
| **M21.In practice, | ||
| M19. Also, , post‑traumatic tendonitis). g.Think about it: 6 | Tenosynovitis, foot | When a tenolysis (27691) is performed to relieve inflammation. Think about it: 8** |
| **M21. | ||
| **M79. | ||
| **M79.In practice, | ||
| M21. Which means , partial tear, enthesopathy). In practice, 7 | Other tendon disorders, foot | For less common PTT pathologies (e. Even so, 4** |
| M21.6 | Other osteoarthrosis, foot | When a concomitant osteotomy (28300/28306) is done for biomechanical correction. 9** |
| M21. 6 | Pain in foot | When pain is the primary complaint and no specific tendon pathology is documented. Even so, |
| M21. 7 | Pain in ankle | For cases where the PTT problem is secondary to ankle pathology. |
Tip: Always confirm the primary diagnosis in the operative note. If the note lists “PTT rupture” but the ICD code is M19.6, the claim will likely be rejected for “lack of medical necessity.”
7. Final sanity check before submission
| Item | What to verify | Why it matters |
|---|---|---|
| Laterality | RT or LT? Bilateral? | Incorrect laterality can trigger denials or result in a single‑code claim. |
| Modifiers | 59 (separate incision), 51 (multiple procedures), 22 (increased services) | Over‑use of modifiers can raise audit flags; under‑use can leave money on the table. Think about it: |
| Bundled vs. On the flip side, unbundled | Is the spring ligament repair truly separate? And | Some payers consider it unlisted; others bundle it with the PTT repair. So |
| Documentation of graft | Harvested plantaris vs. allograft? Because of that, | Determines 28200 vs. 28202. Worth adding: |
| Surgical approach | Medial vs. Practically speaking, lateral incision? | 59 modifier may be required if the approach is distinct. |
| Diagnosis‑procedureѓ alignment | Are the procedures justified by the ICD‑10 codes? | Avoids “medical necessity” denials. |
8. Payer‑specific nuances
| Payer | Key Points |
|---|---|
| Medicare (Part B) | 28202 is reimbursed at 100% of the national fee schedule; 28200 at 100%. That said, the spring ligament repair is unbundled and should be coded 29999. 51 modifier is auto‑applied for the second code. |
| Commercial (Blue Cross, Aetna, etc.) | Many commercial plans bundle 28202 with 27691 if the tenolysis is on the same tendon. Use 59 if a second tendon is tenolized. Spring ligament repair is often unlisted, but some plans allow 28585 if documentation supports a ligament repair. |
| Medicaid | State‑specific rules vary. Some states list spring ligament repair under 29999; others bundle it. Consider this: always check the state’s fee schedule. |
| Military/VA | VA’s fee schedule often mirrors Medicare but may have additional modifiers (e.g., XS for separate incision). |
