Microvascular transfer of two toes (neither the great toe) to reconstruct two absent or amputated digits on the hand.

Verified May 8, 2026 · 6 sources ↓

Medicare: $3,425.93
Total RVUs: 102.57
Global, days: 90
Region: Hand

Drawn from CMSAAPCAbosEmednyFastrvu

Documentation requirements

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

Source · Editorial brief grounded in 6 cited references ↓

Specify which two toes were harvested (e.g., second and third toe, left foot) and the recipient digits by position
Document each microvascular anastomosis performed, including vessel type (artery, vein) and technique
Confirm preoperative diagnosis — traumatic digit loss or congenital absence — with supporting ICD-10 codes
Operative note must distinguish this as a double transfer; a single transfer dictates 26553 instead
Name the approach and reconstruction goal for each toe-to-hand unit (functional grip, thumb opposition, etc.)
Document intraoperative perfusion assessment confirming vascular patency for both transfers before closure
If operating microscope was used, document its employment to support separate billing of 69990

Applicable modifiers

Modifiers commonly billed with this code.

Source · AMA CPT modifier descriptors · CMS NCCI Policy Manual

22 Increased complexity 51 Multiple procedures 52 Reduced services 62 Co-surgeons 74 Discontinued post-anesthesia 78 Unplanned return — related 79 Unrelated during global 80 Assistant surgeon LT Left side RT Right side

What this code covers

Source · Editorial summary grounded in 6 cited references ↓

CPT 26554 covers the simultaneous free-tissue transfer of two non-great toes to the hand using microvascular anastomosis — reconnecting the donor vessels, nerves, bones, and tendons at the recipient site. The procedure addresses traumatic or congenital absence of multiple digits where pollicization or prosthetics are not viable options. Each toe arrives as a composite flap, requiring meticulous vascular coaptation to restore blood flow to both transfers in a single operative session.

This is a high-complexity reconstructive case that routinely involves a two-surgeon team (foot harvest and hand preparation occurring simultaneously), operating microscope use, and lengthy operative time. Code 69990 (operating microscope) is separately reportable with 26554 per CPT guidelines. The 90-day global period covers all routine post-op management, so any unrelated procedure or E/M during that window requires modifier 24 or 79.

Distinguish 26554 from 26553 (single non-great toe transfer) and 26551 (great toe wrap-around with bone graft). Billing 26554 requires documentation of two discrete toe-to-hand microvascular transfers — not a single transfer with bilateral components.

RVU & reimbursement

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

Source · CMS Physician Fee Schedule, RVU26A · January 2026

Work RVU	55.58
Practice expense RVU	35.11
Malpractice RVU	11.88
Total RVU	102.57
Medicare national rate	$3,425.93
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	$3,425.93
HOPD (APC 5114) Hospital outpatient department	$7,413.38
ASC (PI J8) Ambulatory surgical center (freestanding)	$4,682.29

Common denial reasons

The recurring reasons claims for CPT 26554 get rejected.

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

Code submitted as 26553 (single transfer) when two non-great toes were transferred — undercoding that survives claim submission but is clinically inaccurate
Missing or inadequate documentation of dual microvascular anastomoses, causing payer to downcode to 26553
ICD-10 diagnosis does not specify digit absence or amputation, triggering medical necessity denial
Claim lacks operative report confirming two separate toe harvest sites and two recipient hand sites
Modifier 51 incorrectly applied when billing 69990 alongside 26554 — 69990 is exempt from modifier 51
Post-op E/M billed without modifier 24, denied because it falls inside the 90-day global period

Frequently asked questions

Source · Generated from the editorial pipeline, verified against 6 cited references ↓

01Can I bill 26553 twice instead of 26554 for a double transfer?

No. CPT 26554 is the correct code when two non-great toes are transferred in a single operative session. Billing 26553 twice will trigger NCCI bundling edits and likely result in denial or recoupment on audit.

02Is the operating microscope separately billable with 26554?

Yes. CPT 69990 is separately reportable with 26554 when microsurgical technique is employed. Do not append modifier 51 to 69990 — it is add-on-exempt. Document microscope use explicitly in the operative note.

03What modifiers apply when a two-surgeon team performs this case simultaneously?

Use modifier 62 (co-surgeons) when two surgeons of different skills perform distinct portions — for example, one harvesting the foot while the other prepares the hand recipient sites. Each surgeon bills 26554-62. Both operative reports must document the distinct roles.

04Does the 90-day global cover donor site complications at the foot?

Routine post-op management of the donor foot falls inside the global package for the operating surgeon. A separately identifiable complication requiring return to the OR for a related procedure bills with modifier 78; an unrelated procedure uses modifier 79.

05What ICD-10 codes support medical necessity for 26554?

Traumatic amputation codes (e.g., S68.x series) and congenital absence of fingers (Q71.3x) are the primary drivers. Payers often require the diagnosis to specify multiple digits — a general 'hand injury' code without digit-level detail risks medical necessity denial.

06Is 26554 payable in an ASC setting?

Yes. CMS assigns an ASC payment rate for 26554 — see the Site of Service comparison on this page. HOPD payment is higher. Given operative complexity and post-transfer monitoring requirements, many payers and facilities require inpatient admission instead, which shifts billing to the facility DRG rather than ASC rates.

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 number and identity of donor toes harvested, recipient digit positions, each vascular anastomosis performed, intraoperative perfusion confirmation, and operating microscope use — all in structured fields tied directly to 26554 and 69990. This prevents the most common audit flag: an operative note that fails to document two discrete microvascular transfers, which forces a downcode to 26553.

See how Mira captures CPT 26554 documentation