CPT code 27385 – Quadriceps and hamstring muscle rupture repair

Key takeaways

CPT code 27385 covers primary (acute) suture repair of a quadriceps or hamstring muscle rupture under a single descriptor.

CPT 27386 covers secondary repair or reconstruction with a graft, and billing the wrong one of the two is a common denial trigger.

Spontaneous ruptures pair with M66.251/M66.252 (quadriceps, extensor tendons) or M66.351/M66.352 (hamstring, flexor tendons), while traumatic injuries use the S76 series.

The 2026 Medicare national rate is about $588 from 17.62 total RVUs, and the code carries a 90-day global period.

Pabau’s claims management software sends claims through the Claim.MD clearinghouse, which checks CPT and ICD-10 pairings before submission.

CPT code 27385: Descriptor, code attributes, and quick-reference facts

CPT code 27385 covers suture of quadriceps or hamstring muscle rupture performed as a primary repair, meaning the repair is done acutely following injury.

The American Medical Association (AMA), which maintains the CPT code set, publishes the full descriptor as: Suture of quadriceps or hamstring muscle rupture; primary.

The single descriptor covers both the quadriceps and the hamstring muscle group, so you don’t need a separate code for each muscle. It does not cover reconstruction with a fascial or tendon graft, or repair with augmentation material. If the op note mentions a graft, query the surgeon before submitting, because CPT 27386 covers secondary reconstruction with a graft.

Clinical context coders need from the op report

Op report language points to the right code once you know how these injuries happen. A quadriceps tendon rupture typically follows sudden eccentric loading of the knee, such as landing from a jump, stumbling on stairs, or direct trauma. Hamstring ruptures occur at the proximal or distal attachment after explosive hip flexion against resistance.

For orthopedic groups, these repairs are routine surgical cases, and timing decides the code more often than anatomy does. Primary repair means the surgeon closes the rupture acutely, before the tendon retracts and before fibrosis makes direct suture impractical.

Most clinical sources place this window within about two to three weeks of injury, though the AMA descriptor sets no day limit. Op report phrases that signal primary repair include “direct end-to-end repair,” “acute tear,” “minimal retraction,” and “primary suture closure.”

CPT 27385 vs CPT 27386: Primary vs secondary repair coding

CPT 27385 (primary repair) and CPT 27386 (secondary repair) form a classic CPT pairing, where the same anatomical procedure is coded differently based on timing. Selecting the wrong one is a common reason claims for this surgery are denied or downcoded.

When timing is ambiguous, such as when a patient delayed seeking care, the operative report is the deciding document. Look for significant scar tissue requiring mobilization, or a tendon that could not be approximated without tension. Either finding makes 27386 more defensible, whatever the days elapsed. The three checks below run in the order a coder should apply them.

Related codes and how to tell them apart

Several neighboring codes cover knee and thigh tendon repairs. Choosing the wrong one, particularly 27380, triggers NCCI bundling conflicts or medical-necessity denials because the anatomical site differs from what 27385 covers.

ICD-10 diagnosis codes that pair with CPT code 27385

Every CPT 27385 claim requires a paired ICD-10-CM diagnosis code that establishes medical necessity. The CPT-to-ICD-10 crosswalk shows two primary code families: M66 for spontaneous (non-traumatic) ruptures and S76 for traumatic muscle injuries. A code from the wrong family, or a parent code without the laterality digit, causes a medical-necessity denial. The ICD-10-CM code library lists both families with full descriptors.

Always use the 7th character “A” (initial encounter) on S76 codes for the active surgical visit. Traumatic hamstring injuries sit in their own subcategory, S76.3-, which covers the posterior muscle group at thigh level. Pairing a spontaneous-rupture code (M66) with a narrative that describes trauma, or the reverse, is an inconsistency that payer audit systems flag automatically. Verify current laterality subcodes each year in the CDC/NCHS ICD-10-CM web tool, because codes update every October.

Medicare reimbursement and RVU breakdown for CPT code 27385

Medicare reimbursement for CPT code 27385 is calculated from the CMS Physician Fee Schedule (MPFS). Rates vary by location through a geographic practice cost index (GPCI) multiplier. The national average below is a planning reference, not a guarantee of what your practice will receive.

These are national values from the 2026 MPFS. Use the FastRVU lookup tool or the CMS MPFS Look-Up Tool to confirm current-year values for your locality. Commercial payers typically reimburse at a percentage of MPFS, anywhere from 100% to 150% depending on your contract.

90-day global period: What it covers and what bills separately

CPT code 27385 carries a 90-day global surgery period under CMS policy. Most physician services related to the repair are bundled into the single surgical fee for 90 days after surgery. Billing a separate E&M visit or follow-up within that window without a modifier results in a denial or recoupment.

What the 90-day global period includes:

• The pre-operative visit on the day before or the day of surgery
• Intraoperative services and the surgeon’s technical work during the procedure
• All routine post-operative visits within 90 days that are directly related to the repair
• Complications arising from the surgery that do not require a separate return to the operating room

What can still be billed separately within the 90-day window:

• Modifier 24 (unrelated E&M): A new, unrelated condition presenting during the global period, which must carry a completely different diagnosis
• Modifier 25 (significant, separately identifiable E&M on the day of surgery): Used when the surgeon performs a significant evaluation beyond what the pre-op requires
• Modifier 57 (decision for surgery): Used when the decision to operate is made the day before or the day of the procedure
• Modifier 79 (unrelated procedure during global period): Used if the patient needs an entirely separate surgery within 90 days

Modifiers: When and how to append them

Modifier selection for CPT code 27385 is straightforward on most claims, but laterality and NCCI-related modifier errors cause many of its denials. The table below covers the modifiers most often required or questioned for this code.

Prior authorization requirements for knee tendon repair

Prior authorization (PA) requirements for CPT code 27385 vary by payer and plan type. Maintaining medical billing compliance means checking authorization rules per payer, rather than assuming a Medicare policy applies to a commercial plan.

• Medicare (traditional): Traditional Medicare generally does not require prior authorization for CPT 27385. Medicare Advantage plans differ and must be verified individually.
• Medicaid: PA requirements vary by state, and some state programs require authorization for all musculoskeletal surgeries. Check the state Medicaid program’s rules before scheduling.
• Commercial payers: Many commercial plans require PA for surgical codes in the 27000-27599 range. Confirm through the payer portal or a benefit verification call before surgery.

A PA request for this surgery commonly needs:

• MRI or ultrasound imaging confirming the rupture
• The operative plan confirming a primary repair technique
• The surgeon’s clinical notes supporting urgent repair
• Records of any conservative treatment, where the payer’s policy asks for them

Running insurance eligibility verification before the procedure date confirms active coverage and surfaces plan-level PA requirements before they turn into denials. A claim submitted without a required PA is typically non-payable, and under most commercial contracts the practice cannot bill the patient for it.

NCCI edits and bundling rules

The National Correct Coding Initiative (NCCI) edits define which code combinations CMS always bundles (column 1/column 2 pairs) and which a modifier can override. Checking the NCCI table before billing CPT code 27385 with any other same-session code prevents automatic rejection. A grounding in medical billing fundamentals helps coders read NCCI logic correctly.

Key NCCI considerations for 27385:

• 27385 + 27386: These codes are mutually exclusive, because they describe the same repair at different timing stages. Billing both on the same date of service is not payable, whatever modifier is used.
• 27385 + 27380: The infrapatellar tendon code and the quadriceps/hamstring code cover different structures. Billing both for separate, documented tendon injuries in one session may be supported with modifier 59 and a clear op note.
• 27385 + E&M codes: Same-day E&M visits need modifier 25 (significant, separately identifiable service) or 57 (decision for surgery) to bypass the bundling edit.
• Anesthesia codes: The anesthesiologist bills these separately, and they do not create NCCI conflicts with the surgeon’s 27385 claim.

Always verify against the current NCCI Policy Manual for Medicare Services. CMS updates the edit tables quarterly, so a code pair that was payable last quarter may be bundled today.

Documentation requirements: What the operative report must include

A complete operative report is the primary audit defense for CPT code 27385. Coders should check the op note against this list before assigning the code. If any element is missing, query the surgeon before submission rather than coding from an incomplete record.

• Confirmation of acute tear: The note states the tear was acute or recent. Or it describes findings consistent with primary repair, such as minimal retraction, no significant scarring and viable tissue
• Anatomical site: It names the quadriceps tendon or hamstring explicitly, as in “distal quadriceps tendon” or “proximal hamstring at ischial tuberosity”
• Laterality: Right or left side is stated clearly, which supports modifier RT or LT and the laterality digit in the ICD-10 code
• Suture technique: The repair method (transosseous tunnels, suture anchor fixation, end-to-end suture) is described with suture type and size
• Absence of graft: The note confirms no allograft, tendon transfer, or augmentation material was used, since a graft rules out 27385
• Primary nature of repair: Language such as “primary repair,” “direct approximation,” or “acute rupture repair” supports the code and separates it from secondary repair

Incomplete op notes are among the most preventable causes of surgical denials, so denial management in healthcare starts before the claim is built. A standard post-op note checklist gives coders the same six elements to look for on every case. Submitting a clean claim for a surgical code like 27385 starts with the operative note, not the billing screen.

Common denial reasons and how to prevent them

Claims for CPT code 27385 are denied for a predictable set of reasons. Each one has a fix that belongs in the practice’s pre-submission workflow.

1. Wrong code selected (27386 billed instead of 27385): Review the op note for timing and tissue findings before coding. If the note describes chronic features, query the surgeon or use 27386.
2. Missing or wrong ICD-10 code: A parent code without a laterality digit, such as M66.35, triggers a medical-necessity denial. So does an S76 code for a non-traumatic rupture. Always use the most specific lateralized code.
3. Missing prior authorization: Commercial plans routinely deny surgical codes without a valid PA number. Verify PA before the procedure date, not at claim submission.
4. Laterality modifier omitted: Most commercial payers and many Medicare Advantage plans require RT or LT on unilateral musculoskeletal procedures. Omitting it causes automatic rejection.
5. Global period conflict: A follow-up E&M billed inside the 90-day global window without modifier 24 is denied. Build a global-period tracker into your scheduling workflow for surgical patients.
6. NCCI bundling conflict: Billing 27385 with a bundled companion code on the same day without a valid modifier gets the claim rejected. So does overriding a mutually exclusive edit. Check NCCI tables before submission.
7. Timely filing: Most payers set a 90-180 day filing limit from the date of service. Surgical claims often stall in the billing queue, so run a billing review 30 days after each surgery.

How Pabau keeps CPT 27385 claims clean before submission

Without connected software, a coder reads the op note, chooses between 27385 and 27386, and adds RT or LT. Then the claim is re-keyed into a separate payer portal. Each hand-off is another chance to drop a modifier or a laterality digit.

Pabau, the practice management platform we build, keeps the op note, the diagnosis codes and the claim in one patient record. Its orthopedic claims management tools build the claim from that record, so the codes match the documented side and diagnosis.

Claims then go out electronically through Claim.MD, Pabau’s US clearinghouse partner. As the Claim.MD clearinghouse integration guide explains, it scrubs each claim for CPT and ICD-10 pairing errors and NCCI conflicts before the payer sees it.

The billing team then spends its time on payer disputes worth fighting, instead of resubmitting claims rejected for a missing modifier.

Submit cleaner orthopedic surgery claims

Pabau keeps the op note, diagnosis codes and claim in one patient record. Claims go out through Claim.MD, which checks CPT and ICD-10 pairings before submission.

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Conclusion

For CPT 27385, the operative note decides the claim. A note that documents an acute tear, direct suture, no graft and a named side holds up to audit. If any of those is missing, query the surgeon before submission rather than after a denial.

The trade-off is a few minutes of review per case against a 90-day global package worth about $588 at the Medicare national rate. Book a demo to see how Pabau carries the op note through to a clean orthopedic claim.

Continue your research

Need to understand how denial codes map to specific claim errors? Denial codes in medical billing explains the most common CARC denial reason codes and how to respond to each one.

Want to see how a clearinghouse reduces rejection rates for surgical codes? Pabau’s Claim.MD clearinghouse integration covers how real-time claim scrubbing catches NCCI and ICD-10 errors before they reach the payer.

Looking for a complete revenue cycle management reference? What is revenue cycle management walks through the end-to-end billing process from eligibility verification through payment posting.

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