Surgical release of an extensor tendon from adhesions, spanning from the finger through the forearm (tenolysis)

Verified May 8, 2026 · 8 sources ↓

Medicare: $660.67
Work RVU: 8.38
Global, days: 90
Region: Hand

Drawn from CMSMdclarityBedrockbillingAAPCAxogeninc

Documentation requirements

What must appear in the operative or office note to support the claim.

Source · Editorial brief grounded in 8 cited references ↓

Identify the specific extensor tendon(s) released by name (e.g., extensor digitorum communis to the index finger)
Document the anatomical extent of dissection — confirm the release crossed from the finger into the forearm
Describe the nature and density of adhesions encountered and the technique used to free the tendon
Record active and passive range of motion tested intraoperatively before and after tenolysis to support medical necessity
Note laterality explicitly (left or right hand/forearm) in the operative report and on the claim
If modifier 22 is appended, include a separate cover letter quantifying the additional work and time beyond typical

Applicable modifiers

Modifiers commonly billed with this code.

Source · AMA CPT modifier descriptors · CMS NCCI Policy Manual

22 Increased complexity 50 Bilateral procedure 51 Multiple procedures 52 Reduced services 59 Distinct service 76 Repeat, same physician 77 Repeat, another physician 78 Unplanned return — related 79 Unrelated during global LT Left side RT Right side XS Separate structure

What this code covers

Source · Editorial summary grounded in 8 cited references ↓

CPT 26449 describes extensor tendon tenolysis performed along a tract extending from the finger into the forearm. The procedure frees the tendon from scar tissue or adhesions that restrict gliding and limit finger extension. This is a more extensive release than single-level finger tenolysis codes, reflecting the complexity of dissection across multiple anatomical zones.

The 90-day global period means all routine postoperative care — including wound checks, splint changes, and standard follow-up — is bundled into the surgical payment through day 90. Visits for unrelated conditions require modifier 24; a separately identifiable E/M on the day of surgery requires modifier 25 on the E/M, not the surgical code.

Hand surgery dominates the PUF billing profile for this code. When multiple tendon releases are performed in the same session, list 26449 first (highest RVU), apply modifier 51 to secondary procedures, and confirm NCCI bundling before submitting additional codes. Laterality modifiers LT and RT are expected by most payers — omitting them is a common clean-claim failure.

RVU & reimbursement

Component RVUs and Medicare national rate. Actual payment varies by GPCI locality.

Source · CMS Physician Fee Schedule, RVU26A · January 2026

Work RVU vs. total RVU

The work RVU (8.38) is the surgeon's own effort — the figure physician pay and productivity targets are built on. The total RVU (19.78) adds practice overhead and malpractice, and is what drives the Medicare payment below.

Work RVU	8.38
Practice expense RVU	9.84
Malpractice RVU	1.56
Total RVU	19.78
Medicare national rate	$660.67
Global period	90 days

Payment by site of service

Medicare pays different rates by setting. HOPD typically pays substantially more than ASC for the same procedure.

Source · CMS OPPS Addendum B·ASC HCPCS payment rates·2026

Setting	Medicare rate (national)
Office (PFS non-facility) Procedure performed in physician's office	$660.67
HOPD (APC 5113) Hospital outpatient department	$3,342.87
ASC (PI A2) Ambulatory surgical center (freestanding)	$1,644.87

Common denial reasons

The recurring reasons claims for CPT 26449 get rejected.

Source · Editorial brief grounded in CMS NCCI edits, AAOS coding appeals, and cited references ↓

Missing or ambiguous laterality — payers reject claims without LT or RT when the code is inherently unilateral
Operative note documents release confined to the finger only, not extending to the forearm, mismatching the code descriptor
Bundling conflict when a related tendon procedure is billed same-day without modifier 59 or XS to establish a distinct structure
Lack of documented intraoperative range-of-motion testing, undermining medical necessity for tenolysis vs. a less extensive release
Global period violation — E/M billed during the 90-day postoperative period without modifier 24 for an unrelated diagnosis

Frequently asked questions

Source · Generated from the editorial pipeline, verified against 8 cited references ↓

01What distinguishes 26449 from a finger-only extensor tenolysis code?

26449 requires that the release extend from the finger into the forearm. If the tenolysis is confined to the finger, a different tenolysis code applies. The operative note must document dissection crossing that boundary — audit reviewers look for this specifically.

02Can 26449 be billed bilaterally in the same session?

Yes. Apply modifier 50 if both hands are treated in the same operative session. Confirm individual payer preference — some require a single line with modifier 50, others require two lines with LT and RT. The Axogen tendon coding guide notes this payer variability explicitly.

03Is modifier 51 required when 26449 is billed alongside another surgical code?

Yes, when 26449 is not the highest-RVU procedure in the session, place modifier 51 on it to signal a secondary procedure subject to the multiple-procedure payment reduction. If it is the primary code, list it first without modifier 51.

04When is modifier 78 appropriate for 26449 versus modifier 79?

Use modifier 78 if the patient returns to the OR during the global period for a complication or issue directly related to the original tenolysis — for example, re-release of recurrent adhesions from the same tendon. Use modifier 79 for a procedure on a different, unrelated structure or condition during the same global period. Inverting them is a compliance error.

05What ICD-10 diagnoses typically support medical necessity for this procedure?

Tendon adhesions following trauma, prior surgery, or infection are the typical drivers — look to M67 series (tendon disorder) and post-traumatic or post-surgical sequela codes. The operative note must connect the specific diagnosis to functional limitation justifying surgical release.

06Does the 90-day global period affect physical therapy orders written after surgery?

The global covers only physician services. Separately billed PT by a therapist is not bundled into the surgical global and can be billed independently. However, any physician-directed postoperative visit for routine wound or tendon follow-up within 90 days is bundled — bill those only with modifier 24 if the visit is for an unrelated condition.

Sources & references

Editorial content was developed using the following public sources. Last verified May 8, 2026.

Mira Scribe

Mira's AI scribe captures the specific extensor tendon name and digit, the proximal extent of dissection into the forearm, the character of adhesions encountered, and intraoperative pre- and post-release range-of-motion measurements from dictation. That detail prevents the most common audit flag: an operative note that describes a finger-only release billed under a finger-to-forearm code.

See how Mira captures CPT 26449 documentation