CPT code 20924: Tendon graft billing and 2026 RVUs

Key takeaways

CPT code 20924 covers the surgical harvest of a tendon graft from a site distant to the repair, such as the palmaris longus.

The code carries 14.07 total RVUs and a 90-day global period, and Medicare pays about $470 in either setting.

Practice expense RVUs match across facility and non-facility work, so the place of service does not change the payment.

Read the primary code’s descriptor before adding 20924, then use modifier 59 or XS if an NCCI edit applies.

Practice management software like Pabau pre-fills the claim from the client record and checks required fields before submission.

CPT code 20924 covers the harvest of a tendon graft from a distant site, such as the palmaris longus at the wrist. Surgeons also take a toe extensor tendon or the plantaris in the lower leg. Medicare pays about $470 for that harvest in 2026, and the same amount in either place of service.

Below you’ll find the current RVUs, the 2026 payment math, the modifier rules, the diagnosis pairings, and a pre-submission checklist.

What CPT code 20924 covers, and what it doesn’t

The official descriptor is short. It reads Tendon graft, from a distance (e.g., palmaris, toe extensor, plantaris).

The American Medical Association, which maintains the CPT code set, files it under General Grafts (or Implants) in the Musculoskeletal System section. Hand and reconstructive surgeons bill it most often, so it turns up regularly in plastic surgery documentation.

The load-bearing word in that descriptor is “distance”. The donor site has to sit away from the area being rebuilt. Harvest a tendon from the same region as the repair and you’re looking at a local graft, which carries its own code.

If the surgeon reroutes a nearby tendon instead of taking a free graft, that’s a transfer, and codes such as 25310 apply instead.

When surgeons reach for 20924

20924 shows up when the reconstruction needs the patient’s own tendon and no local donor will do. Orthopedic, hand, and sports medicine surgeons bill it most, and it appears in facial reconstruction too.

• ACL reconstruction: the palmaris longus or plantaris reinforces a hamstring graft that measures too small on its own. Neither tendon replaces a hamstring or patellar graft outright.
• Flexor tendon repair in the hand: a toe extensor or palmaris longus graft bridges a long defect in the palm or fingers.
• Ulnar collateral ligament reconstruction: elbow surgeons rebuild the ligament with a palmaris longus graft, though the elbow codes already include the harvest.
• Extensor tendon repair: a distant donor tendon rebuilds an extensor mechanism that can’t be repaired with local tissue.
• Eyelid and facial work: palmaris longus grafts are used in ptosis correction and facial reanimation procedures.

The operative note carries the medical necessity argument, so it needs to name three things.

Start with the diagnosis driving the reconstruction. Then explain why a distant donor beat a local or allograft source. Finally, record the exact tendon harvested and where it came from.

The operating surgeon and the facility bill the harvest, not the therapy team who picks up the patient afterward.

RVU values don’t change with the place of service

CMS lists identical relative value units for 20924 in both settings. Work is 6.51, practice expense is 6.33, and malpractice is 1.23, for 14.07 total in a hospital and in an office.

You can confirm the current figures in the CMS fee schedule lookup.

Matching practice expense values are unusual, and they make your estimate simpler. There’s no facility versus office math to run here, because the place of service doesn’t move the physician payment.

Geography still does. The geographic practice cost index applies locality multipliers to each component, so the same claim pays differently in San Francisco and in rural Kansas.

What Medicare pays for CPT code 20924 in 2026

Multiply 14.07 total RVUs by the 2026 conversion factor and you land just under $470.

CMS finalized two factors this year. Practices outside an advanced alternative payment model use $33.4009, and qualifying participants use $33.5675, per the CY 2026 final rule.

Those figures use the $33.4009 factor, which works out at $469.95. Qualifying participants land near $472.

Locality adjustment moves the number in both directions, with high-cost areas paying above the national average and rural areas below it. Commercial contracts are a separate exercise, and they often pay more than Medicare for surgical work.

Modifier 59 or XS keeps the harvest unbundled

When 20924 is separately reportable and an NCCI edit sits on the pair, modifier 59 or an X modifier releases it.

XS is the sharper choice, because the harvest happens at a separate structure from the repair. Modifier indicators in the NCCI edit files tell you whether an override is allowed at all.

Payer preferences split here. Some plans accept 59, others insist on the X modifiers, and a few reject the pairing whatever you append.

Check the contract before you submit, then write the answer down. A short payer-by-payer note saves the next coder from repeating the same research, and it gives you something to point at during an appeal.

Which ICD-10 codes support a 20924 claim

The diagnosis comes from the condition driving the reconstruction, never from the harvest. A donor site incision has no diagnosis of its own.

Pair 20924 with a wrist code just because the palmaris came from the wrist and you’ve handed the payer a reason to deny the line.

Specificity does the work in this family, because the codes split by level rather than by joint. A right hand extensor rupture is M66.241, while the same rupture at forearm level is M66.231.

Crepitant synovitis follows the same pattern, with M70.041 for the right hand and M70.031 for the right wrist.

Laterality is the other audit trigger. A right knee diagnosis sitting next to an LT modifier invites a records request, so the note has to explain a contralateral donor site.

Shoulder-level injuries such as S46.921A and lower-leg injuries such as S86.921A follow the same rule.

When you can bill 20924 separately

20924 earns its own charge line only when the primary procedure code doesn’t already include the harvest and no edit blocks the pair. Work the checks in that order.

The first one settles most cases before you open the edit tables at all.

Start with the primary code’s descriptor

Several reconstruction codes fold the harvest into their own descriptor. CPT 24344 and 24346, the lateral and medial collateral ligament reconstructions of the elbow, both end with “includes harvesting of graft”.

Where that parenthetical appears, the harvest is already paid inside the primary code. No documentation, modifier, or appeal makes 20924 payable alongside it.

So read the descriptor in full before you add the second line. It takes seconds, and it heads off the most expensive version of this error, a denial that shows up weeks after the surgery.

Then run the four-point test

1. Check the NCCI edit. Look for a column 1 or column 2 edit between 20924 and the primary code. A modifier indicator of 1 means an override is allowed, and 0 means it isn’t.
2. Read the operative note. The harvest needs its own incision, dissection, and closure on the page. A passing mention of “palmaris longus harvested” inside the reconstruction narrative won’t hold up.
3. Confirm the payer policy. Medicare and most commercial plans allow the separate line once the first two checks pass. Workers’ compensation and some state Medicaid programs bundle it regardless.
4. Append the right modifier. Add 59 or XS to 20924 as the secondary code, and apply 51 where the payer expects it for multiple procedures.

How a 20924 claim moves from op note to payment

Knowing the route helps you spot where these claims stall. The surgeon dictates the operative note, and the coder pulls two procedure lines from it. The primary reconstruction sits on the first charge line, and 20924 follows underneath with its modifier.

Both lines point at the reconstruction diagnosis, not the donor site, and the claim leaves on a CMS-1500 form. The clearinghouse scrubs it first, which is where a clean claim pays off. The payer adjudicates, and the remittance advice tells you whether the second line survived.

A worked example makes the split obvious. A pitcher has a ulnar collateral ligament reconstruction with a palmaris longus graft, and the surgeon bills 24346 on its own.

Move the same graft to a flexor tendon repair in the hand and the picture changes. The harvest is now a separate step at a separate structure, so 20924 with XS joins the primary repair code.

The 60-second check before you submit

• Primary descriptor read in full, with no harvest language inside it.
• NCCI edit checked for this exact pair, with the modifier indicator noted.
• Operative note names the tendon, the donor site, the incision, and the closure.
• Diagnosis pointer set to the reconstruction diagnosis on both charge lines.
• Laterality on the claim matches the note, including any contralateral harvest.
• Payer policy confirmed, with prior authorization on file where the plan requires it.

Five mistakes that trigger a 20924 denial

1. Unbundling without a modifier. Billing 20924 next to a primary reconstruction with no 59 or XS trips the NCCI edit automatically.
2. The wrong graft type. 20924 is autograft only. The allograft codes run 20930 through 20934, and 20936 through 20938 are spine-only autograft codes.
3. A thin operative note. No tendon name, no donor site, and no incision or closure detail at the harvest site means no separate payment.
4. Laterality mismatch. A right knee diagnosis with an LT modifier on the harvest, and nothing in the note explaining the contralateral donor site.
5. Skipped payer homework. Workers’ compensation plans and some state Medicaid programs bundle the harvest whatever the documentation says.

The remittance tells you which one you hit. CO-97 points at bundling, so check the descriptor and the edit before you appeal.

CO-16 usually means something on the claim is missing or malformed. Our guide to denial codes covers the rest, and denial management covers the workflow around them.

How 20924 differs from the other graft codes

Graft coding turns on three questions. Is the tissue bone, tendon, or cartilage? Does it come from the patient or from a tissue bank? And was it taken nearby or from a distant site?

The table below sorts 20924 from the neighbors it gets confused with.

The 20924 versus 20930 decision is autograft against allograft. Look for “the patient’s own palmaris longus” in the note rather than “tibialis anterior allograft”. Nothing is harvested from the patient in an allograft case, so no harvest code applies.

Spine work runs on its own set, where autograft is 20936 through 20938 and those lines sit alongside instrumentation codes such as 22842.

How Pabau keeps 20924 claims moving

Most orthopedic billing teams run this code across three places. The operative note lives in one system, and the code pair and modifier go into another.

Payer rules live in someone’s head or a shared document. Every hop is a chance to mistype a code or drop a required field.

Practice management software like Pabau closes that distance. Pabau’s claims management software pre-fills the claim from the client record.

Codes attached to the service land on the charge lines, and recorded diagnoses seed the ICD-10 slots. It checks that claim-required fields are complete before the send button unlocks, then submits electronically through the Claim.MD integration in the US.

From there you can track each claim’s status and post remittances against it. A bundled second line then surfaces in days instead of at month end.

Coders still make the modifier call, which is exactly where their judgment belongs. What changes is the retyping and chasing around that decision.

Send orthopedic claims without the retyping

Pabau pre-fills claim forms from the client record, checks that required fields are complete before submission, and tracks every claim’s status through to payment. See how it fits an orthopedic billing workflow.

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Conclusion

20924 is a small line on a large claim, and it behaves predictably once you check the primary descriptor first. Codes that already include the harvest close the question on the spot.

Everything else comes down to the edit, the operative note, and the modifier.

If your team is retyping operative details into claim forms, start there. Book a demo to see how Pabau pre-fills and tracks orthopedic claims straight from the client record.

Continue your research

Coding a joint injection this week? CPT code 20611 covers arthrocentesis with ultrasound guidance, including the recording requirement payers check.

Working an elbow trauma claim? CPT code 24582 sets out the billing rules for percutaneous fixation of a humeral condylar fracture.

Need the wrist equivalent? CPT code 25676 explains how open treatment of a distal radioulnar dislocation is documented and billed.

Pricing a shoulder fracture claim? CPT code 23620 walks through closed treatment of a greater humeral tuberosity fracture.

Billing a spinal deformity case? CPT code 22214 covers lumbar osteotomy, the setting where the spine-only autograft codes turn up.

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