Soft tissue repair · Foot & ankle

27691

Transfer of one or more tendons in the lower leg requiring free tendon graft(s) to restore function, each tendon addressed individually.

Verified May 8, 2026 · 6 sources ↓

Medicare
$702.42
Work RVU
10.23
Global, days
90
Region
Foot & ankle
Drawn from CMSAAPCAbosAAOS

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 tendon(s) were transferred by anatomic name (e.g., peroneus longus, posterior tibial, extensor hallucis longus).
  • Document the source and type of free tendon graft used (autograft vs. allograft, harvest site if autograft).
  • Record the recipient site of reattachment and fixation method (suture anchor, bone tunnel, interference screw).
  • State the indication driving the transfer — not just diagnosis code, but functional deficit (e.g., paralytic drop foot, irreparable peroneal tear, Stage III PTTD).
  • Include intraoperative findings confirming the primary tendon was not repairable without graft augmentation.
  • Note the approach by name and laterality; do not write 'standard approach' — audit teams flag that language.

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 50 Bilateral procedure 51 Multiple procedures 52 Reduced services 58 Staged or related 59 Distinct service 62 Co-surgeons 78 Unplanned return — related 79 Unrelated during global 80 Assistant surgeon LT Left side RT Right side XS Separate structure

What this code covers

Source · Editorial summary grounded in 6 cited references ↓

CPT 27691 covers tendon transfer procedures in the lower leg that require a free tendon graft — meaning the tendon is detached from its origin or insertion and reattached at a new site, with graft material used to bridge the reconstruction. This is a step above simple repair or primary transfer; the free graft requirement is what distinguishes 27691 from codes like 27658 or 27664. Common clinical scenarios include peroneal tendon reconstruction, posterior tibial tendon insufficiency requiring augmentation, and drop-foot correction requiring anterior transfer with graft interposition.

The 90-day global period applies. All routine follow-up, dressing changes, suture removal, and related E/M visits within 90 days are bundled. Bill unrelated problems in the global window with modifier 24; a separate E/M on the day of surgery requires modifier 25 if a distinct, separately documented decision was made. If a complication requires a return to the OR for a related procedure, use modifier 78 — not 79, which is reserved for unrelated procedures during the global.

Site of service matters significantly here. The gap between HOPD and ASC payment rates is substantial — see the site of service comparison table. For bilateral cases (uncommon but possible), append modifier 50 and confirm payer policy; some require separate line items with LT/RT instead.

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 (10.23) is the surgeon's own effort — the figure physician pay and productivity targets are built on. The total RVU (21.03) adds practice overhead and malpractice, and is what drives the Medicare payment below.

Work RVU10.23
Practice expense RVU9.04
Malpractice RVU1.76
Total RVU21.03
Medicare national rate$702.42
Global period90 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

SettingMedicare rate (national)
Office (PFS non-facility)
Procedure performed in physician's office
$702.42
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 27691 get rejected.

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

  • Missing graft documentation: payer downcodes to 27659 or 27665 when the operative note doesn't explicitly confirm a free graft was used.
  • Bundling with same-day tenolysis or repair codes without a supported modifier when separate anatomic sites aren't clearly documented.
  • Medical necessity not established: notes lack functional deficit documentation or fail to show conservative treatment failure before surgical intervention.
  • Laterality missing on the claim — LT/RT absent when payer requires them, triggering automatic edit.
  • Global period violations: post-op E/M billed without modifier 24 for an unrelated condition, or without modifier 25 when a same-day decision visit is billed.

Frequently asked questions

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

01What separates 27691 from 27659 or 27665?
27659 and 27665 are secondary flexor/extensor tendon repairs with or without graft. 27691 is specifically a tendon transfer using a free graft — the tendon is moved to a new functional position, not just repaired in place. If the tendon stays in its anatomic line and you're just bridging a gap, the repair codes may apply instead. When in doubt, your operative note's description of the new insertion site is what determines the correct code.
02Can I bill 27691 twice on the same date for two separate tendons?
Yes — 27691 is described per tendon. Bill a unit for each tendon transferred with a free graft. Append modifier 51 on the second and subsequent units per payer convention. Some payers require separate line items; confirm your MAC's policy. Document each tendon's transfer independently in the operative note.
03Is a same-day tendon harvest separately billable?
Not routinely. Graft harvest is generally considered integral to the transfer procedure when performed at the same site. If the harvest requires a significantly separate incision and effort that substantially increases operative time and complexity, modifier 22 with a supporting operative note narrative is the appropriate pathway — not a separate harvest code.
04How does modifier 78 apply if the patient returns to the OR for graft failure during the 90-day global?
If the return procedure is directly related to the original transfer — such as reattachment of a failed graft or revision of the same tendon — use modifier 78. The global clock does not restart. If the return addresses a completely unrelated problem, use modifier 79. Never invert these; modifier 79 on a related return-to-OR is a common audit finding.
05Does 27691 require a specific ICD-10 to clear medical necessity?
No single ICD-10 is universally required, but payers typically expect codes reflecting structural tendon pathology or neuromuscular dysfunction — such as M66.x (spontaneous rupture), M76.x (tendinopathy), G57.x (peroneal nerve palsy causing drop foot), or M21.37 (foot drop). A mismatch between a benign diagnosis and this high-RVU procedure is a common trigger for pre-payment review.
06Can a podiatrist bill 27691?
Yes — podiatry is among the top billing specialties for this code per CMS PUF data. State scope-of-practice laws govern whether a DPM can perform lower-leg tendon transfer surgery; Medicare coverage follows that scope determination. Credential and NPI type documentation should be current in your payer enrollment files.

Sources & references

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

  1. 01CMS Physician Fee Schedule 2026
  2. 02
    aapc.com
    https://www.aapc.com/codes/cpt-codes/27691
  3. 03
    cms.gov
    https://www.cms.gov/files/document/r13033cp.pdf
  4. 04
    cms.gov
    https://www.cms.gov/files/document/04-chapter4-ncci-medicare-policy-manual-2025finalcleanpdf.pdf
  5. 05
    abos.org
    https://www.abos.org/wp-content/uploads/2019/12/sports-cpt-updated.pdf
  6. 06
    aaos.org
    https://www.aaos.org/quality/resident-guide-to-coding-and-practice-management/coding-reimbursement-for-residents/coding-tools-for-residents/

Mira AI Scribe

Mira's AI scribe captures the tendon name, transfer vector, graft source and type, fixation technique, and intraoperative findings from dictation — populating the operative note fields that payers audit first. That prevents the most common 27691 downcode, which occurs when reviewers can't confirm a free graft was used versus a primary repair.

See how Mira captures CPT 27691 documentation

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