Surgical repair of a failed-to-heal fracture in a metacarpal or phalanx bone, including harvesting a bone graft and stabilizing with external or internal fixation when indicated.

Verified May 8, 2026 · 5 sources ↓

Medicare: $993.34
Total RVUs: 29.74
Global, days: 90
Region: Hand

Drawn from CMSAbosAAPCGenhealth

Documentation requirements

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

Source · Editorial brief grounded in 5 cited references ↓

Identify the specific bone by name and ray (e.g., index finger proximal phalanx, third metacarpal) — 'hand bone' is insufficient for audit defense.
Confirm nonunion diagnosis with imaging (X-ray or CT) showing failure of bony bridging; document the radiographic findings explicitly in the preoperative note.
Describe the bone graft source (autograft from iliac crest, distal radius, etc.), quantity harvested, and placement at the nonunion site.
State the fixation method used — type and configuration of hardware (e.g., 2.0mm plate and screws, K-wires, external fixator) or document that no fixation was placed.
Document debridement of fibrous nonunion tissue and any preparation of the bone ends prior to graft placement.
If prior hardware was removed during the same procedure, note that removal was integral to nonunion access — this prevents an erroneous separate claim for 20670/20680.

Applicable modifiers

Modifiers commonly billed with this code.

Source · AMA CPT modifier descriptors · CMS NCCI Policy Manual

22 Increased complexity 24 Unrelated E/M during global 25 Significant separate E/M 51 Multiple procedures 52 Reduced services 58 Staged or related 59 Distinct service 78 Unplanned return — related 79 Unrelated during global LT Left side RT Right side 80 Assistant surgeon AS PA/NP/CNS assistant

What this code covers

Source · Editorial summary grounded in 5 cited references ↓

26546 covers open repair of a nonunion in any metacarpal or phalanx of the hand. The procedure involves exposing the nonunion site, debriding tissue that is obstructing healing, harvesting autogenous bone graft (typically from the iliac crest or distal radius), placing the graft at the nonunion site, and stabilizing the construct with plates, screws, pins, or external fixators as needed. Bone graft harvest is bundled — do not separately report graft procurement codes.

The 90-day global period covers all routine postoperative care through day 90, including hardware checks and wound management. If hardware removal is performed as a necessary integral part of the nonunion repair (e.g., removing a previously placed pin to access the site), do not separately report 20670 or 20680 per CMS NCCI policy. A separately planned hardware removal on a different date would require modifier 79.

Do not confuse nonunion with malunion. Malunion repair of a metacarpal is reported with 26565 (osteotomy, metacarpal) or 26567 (osteotomy, phalanx) — not 26546. When the operative note describes corrective osteotomy for angular deformity rather than failed healing at a fracture site, 26546 is incorrect. Auditors flag this distinction routinely.

RVU & reimbursement

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

Source · CMS Physician Fee Schedule, RVU26A · January 2026

Work RVU	10.56
Practice expense RVU	17.16
Malpractice RVU	2.02
Total RVU	29.74
Medicare national rate	$993.34
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	$993.34
HOPD (APC 5114) Hospital outpatient department	$7,413.38
ASC (PI A2) Ambulatory surgical center (freestanding)	$3,695.53

Common denial reasons

The recurring reasons claims for CPT 26546 get rejected.

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

ICD-10 diagnosis code reflects acute fracture rather than established nonunion — use M84.3xx codes for stress/nonunion, not S-series acute fracture codes.
Operative report describes corrective osteotomy for malunion (angular deformity) rather than failed healing; payers recode to 26565 or 26567 and deny 26546.
Bone graft harvest billed separately in addition to 26546; graft procurement is bundled per code definition and triggers a NCCI edit.
Postoperative E&M billed during the 90-day global period without modifier 24 or 25; routine follow-up is included in the global and denied without a qualifying modifier.
Missing preoperative imaging documentation to support the nonunion diagnosis; medical necessity denied when clinical record lacks radiographic evidence of nonunion.

Frequently asked questions

Source · Generated from the editorial pipeline, verified against 5 cited references ↓

01Can I bill 26546 for a malunion repair?

No. 26546 is specific to nonunion — failed bony healing. Malunion repair (angular or rotational deformity with healed but malaligned bone) is reported with 26565 for metacarpal osteotomy or 26567 for phalanx osteotomy. The clinical and operative distinction must be explicit in the record.

02Is bone graft harvest separately billable with 26546?

No. The code description includes obtaining the bone graft. Separately reporting graft procurement codes will trigger an NCCI bundling edit and denial.

03If I need to remove a plate placed at a prior surgery to access the nonunion site, do I bill 20680?

No. CMS NCCI policy explicitly states that removal of internal fixation as a necessary integral step of a nonunion repair is not separately reportable. Document that the removal was required for access — do not generate a separate line for 20680.

04What modifier applies if I operate on both the index and ring fingers for nonunion on the same day?

Report 26546 for the primary procedure and 26546-51 for the additional finger. Each nonunion site represents a distinct procedure on a separate bone. Some payers also accept modifier 59 or XS; confirm payer preference before submitting.

05What ICD-10 codes support 26546?

Use M84.34x (stress fracture, hand) or the appropriate nonunion sequela codes under M84.84x for metacarpal/phalanx nonunion. Avoid S-series acute fracture codes — they signal an acute injury, not a failed-healing scenario, and will prompt medical necessity denial.

06How does the 90-day global period affect postoperative billing?

All routine follow-up visits, wound checks, and dressing changes through day 90 are bundled. To bill an E&M during the global for a new problem, append modifier 24 (postoperative visit, unrelated) or modifier 25 (significant separate E&M on the surgical date). Document the unrelated condition explicitly.

Sources & references

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

Mira AI Scribe

Mira's AI scribe captures the specific bone (metacarpal number or phalanx and ray), the nonunion duration and supporting imaging findings, graft source and volume, fixation hardware type, and whether prior hardware was removed as part of exposure. That documentation chain directly satisfies the medical necessity requirement and prevents downcoding to an acute fracture repair or reclassification as a malunion osteotomy — the two most common audit flags for this code.

See how Mira captures CPT 26546 documentation