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Foot and ankle tendon transfers are surgical procedures that involve moving a healthy tendon from one location to another in the foot or ankle to replace the function of a damaged or inactive tendon, or to correct a structural problem. As a podiatry coder, you need to familiarize yourself with the procedure codes so you can assign the correct code on your claim.

Build your foot and ankle tendon transfer knowledge with this handy guide.

Know Why Tendon Transfers Are Needed

Foot and ankle tendon transfers are often done to restore movement or balance in the foot and ankle after a neurological or muscle issue (like foot drop) or to address conditions like flat feet. The procedure also aims to redistribute muscle power rather than recreating it, providing a substitute for lost function.

Below are common conditions that can benefit from tendon transfer procedures:

• Foot drop: Foot drop is a condition where the foot cannot be raised due to damage to the muscles or nerves that control ankle dorsiflexion (pulling the foot up). Tendon transfers can help restore this movement by rerouting a healthy tendon to take over the function of the affected tendon. 
• Flat feet (pes planus): Flat feet can occur when the arch of the foot collapses due to damage to the posterior tibial tendon, which supports the arch. Tendon transfers can be used to reinforce or replace the damaged tendon with a healthy tendon from another part of the foot or leg. 
• Other conditions: Tendon transfers can also be used to address other foot and ankle problems, such as ankle joint instability (e.g., from ligament tears) or to correct bone alignment problems. 

Get to Know the Codes

Foot tendon transfers are coded using various CPT^® codes depending on the specific procedure performed. Here are the most common CPT^® codes for these foot and ankle tendon transfers and their descriptors. Start here when looking for appropriate billing and coding:

• 28200 (Repair, tendon, flexor, foot; primary or secondary, without free graft, each tendon) 
• 28202 (… secondary with free graft, each tendon (includes obtaining graft))
• 28208 (Repair, tendon, extensor, foot; primary or secondary, each tendon)
• 28210 (… secondary with free graft, each tendon (includes obtaining graft))
• 27690 (Transfer or transplant of single tendon (with muscle redirection or rerouting); superficial (eg, anterior tibial extensors into midfoot))
• 27691 (… deep (eg, anterior tibial or posterior tibial through interosseous space, flexor digitorum longus, flexor hallucis longus, or peroneal tendon to midfoot or hindfoot)) 
• 28238 (Reconstruction (advancement), posterior tibial tendon with excision of accessory tarsal navicular bone (eg, Kidner type procedure))
• 28313 (Reconstruction, angular deformity of toe, soft tissue procedures only (eg, overlapping second toe, fifth toe, curly toes)) 

Learn How a Tendon Transfer Procedure Works

To start a tendon transfer, the surgeon identifies a healthy tendon with a functional muscle. The physician detaches the tendon from its original attachment and reattaches it to a different location, often to another bone or tendon. A tunnel may be created through a bone to allow the tendon to pass through, and then the tendon is secured in place with sutures, screws, or other anchors. 

Common tendon transfer procedures include:

• Posterior tibial tendon (PTT) transfer: A physician performs this procedure to address foot drop or flat feet. The PTT is transferred to the top of the foot to restore dorsiflexion or to reinforce the arch. 
• Anterior tibial tendon (ATT) transfer: The surgeon uses this transfer to correct foot drop by rerouting the ATT to dorsiflex the foot. 
• Flexor digitorum longus (FDL) to PTT: This transfer is used to replace the damaged PTT in flat feet. 
• Peroneus brevis or longus transfer: Physicians address lateral ankle instability or assist with foot drop with these transfer procedures. 

Remember This Advice When Billing Tendon Transfers

Codes like 27690-27691 and codes from the 28200-28210 range are frequently used for tendon transfers and repairs in the foot and ankle. The choice of code depends on factors such as the tendon’s location (flexor or extensor), whether a graft is involved, and the specific surgical technique used. 

Examine the following considerations for coding and billing:

• Location: Determine if the tendon transfer is at the ankle/leg level (e.g., 27690, 27691) or within the foot itself (e.g., 28200, 28202). 
• Tendon type: Differentiate between flexor and extensor tendons (e.g., 28200 vs. 28208). 
• Graft: Documentation should indicate if a free graft was used in the repair (e.g., 28202, 28210). 
• Primary vs. secondary: Distinguish between primary and secondary repairs (e.g., 28200 vs. 28202). 
• Extensive procedures: For complex transfers or those with additional procedures, consider using modifiers like 22 (Increased procedural services) or 59 (Distinct procedural services). 
• Unlisted codes: If a procedure does not have a specific CPT^® code, use an unlisted code such as 28899 (Unlisted procedure, foot or toes). 
• Bundling issues: Be aware of potential bundling issues, where Medicare or other payers may consider certain procedures inclusive of others performed during the same encounter. 
• Global surgical package: Understand the global surgical package for foot and ankle procedures, which includes preoperative, intraoperative, and postoperative care. 
• Documentation: Thorough documentation in the operative report is crucial for justifying the chosen codes and supporting medical necessity. 
• Consult coding resources: Refer to the CPT^® code book and other coding resources, like the American Orthopedic Foot & Ankle Society (AOFAS) website, for specific guidance. 

See How the Codes Relate to Real-World Scenarios

Example 1: A surgeon performs a transfer of flexor digitorum longus tendon to posterior tibial tendon. You’ll assign 27691 to report the single, deep tendon-transfer procedure.

Example 2: A physician repairs a flexor tendon in the patient’s foot without using a graft. Use 28200 to report this procedure. 

Example 3: The provider performs a repair of an extensor tendon in the foot with a free graft. Assign 28210 to report the extensor tendon repair with a free graft. 

Example 4: A surgeon performs a Jones tendon suspension, which involves transferring the extensor hallucis longus (EHL) tendon to the first metatarsal. Consider using 28760 to report this procedure.

With tendon transfers that affect the feet and ankles, always keep in mind that you must rely heavily on the providers’ detailed and specific operative reports, which should include the specific tendons, their locations, and whether a graft is used. If any of these components are missing from the documentation, the coder should refer back to the operating provider to ensure the note is updated accordingly. Accurate documentation and coding are essential for proper billing and reimbursement. 

Jessica Sullivan, CPC, COBGC, COSC, Consultant, Pinnacle Enterprise Risk Consulting Services