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The procedure described by CPT® Code 21010 refers to an arthrotomy of the temporomandibular joint (TMJ). This surgical intervention involves making a skin incision in front of the ear, which is a strategic location that allows access to the TMJ. The incision is extended through the subcutaneous tissue, reaching the superficial layer of the deep temporal fascia, which is a fibrous tissue layer that covers the muscles of the temple region. During the procedure, the surgeon identifies and protects the temporal branch of the facial nerve, a critical structure that innervates muscles of facial expression. Once the joint space is accessed, the surgeon inspects the TMJ for any abnormalities, which may include signs of inflammation, degeneration, or other pathological conditions. If necessary, tissue samples can be obtained for further analysis, and minor procedures may be performed to address specific issues within the joint. After the necessary interventions are completed, the incision is meticulously closed in layers to promote optimal healing and minimize scarring.
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The indications for performing an arthrotomy of the temporomandibular joint (CPT® Code 21010) typically include the following conditions:
The procedure for an arthrotomy of the temporomandibular joint involves several critical steps to ensure proper access and intervention within the joint space:
Post-procedure care following an arthrotomy of the temporomandibular joint typically involves monitoring for any signs of complications, such as infection or excessive swelling. Patients may be advised to follow specific guidelines regarding pain management, activity restrictions, and dietary modifications to facilitate healing. Follow-up appointments are essential to assess recovery and to determine if further interventions are necessary. The expected recovery time may vary depending on the extent of the procedure and the individual patient's health status.
| Short Descr | INCISION OF JAW JOINT | Medium Descr | ARTHROTOMY TEMPOROMANDIBULAR JOINT | Long Descr | Arthrotomy, temporomandibular joint | Status Code | Active Code | Global Days | 090 - Major Surgery | PC/TC Indicator (26, TC) | 0 - Physician Service Code | Multiple Procedures (51) | 2 - Standard payment adjustment rules for multiple procedures apply. | Bilateral Surgery (50) | 1 - 150% payment adjustment for bilateral procedures applies. | Physician Supervisions | 09 - Concept does not apply. | Assistant Surgeon (80, 82) | 0 - Payment restriction for assistants at surgery applies to this procedure... | Co-Surgeons (62) | 0 - Co-surgeons not permitted for this procedure. | Team Surgery (66) | 0 - Team surgeons not permitted for this procedure. | Diagnostic Imaging Family | 99 - Concept Does Not Apply | APC Status Indicator | Hospital Part B services paid through a comprehensive APC | ASC Payment Indicator | Surgical procedure on ASC list in CY 2007; payment based on OPPS relative payment weight. | Type of Service (TOS) | 2 - Surgery | Berenson-Eggers TOS (BETOS) | P5B - Ambulatory procedures - musculoskeletal | MUE | 1 | CCS Clinical Classification | 162 - Other OR therapeutic procedures on joints |
This is a primary code that can be used with these additional add-on codes.
| 20700 | Add-on Code MPFS Status: Active Code APC N ASC N1 Manual preparation and insertion of drug-delivery device(s), deep (eg, subfascial) (List separately in addition to code for primary procedure) |
| 50 | Bilateral procedure: unless otherwise identified in the listings, bilateral procedures that are performed at the same session, should be identified by adding modifier 50 to the appropriate 5 digit code. note: this modifier should not be appended to designated "add-on" codes (see appendix d). | 51 | Multiple procedures: when multiple procedures, other than e/m services, physical medicine and rehabilitation services or provision of supplies (eg, vaccines), are performed at the same session by the same individual, the primary procedure or service may be reported as listed. the additional procedure(s) or service(s) may be identified by appending modifier 51 to the additional procedure or service code(s). note: this modifier should not be appended to designated "add-on" codes (see appendix d). | 52 | Reduced services: under certain circumstances a service or procedure is partially reduced or eliminated at the discretion of the physician or other qualified health care professional. under these circumstances the service provided can be identified by its usual procedure number and the addition of modifier 52, signifying that the service is reduced. this provides a means of reporting reduced services without disturbing the identification of the basic service. note: for hospital outpatient reporting of a previously scheduled procedure/service that is partially reduced or cancelled as a result of extenuating circumstances or those that threaten the well-being of the patient prior to or after administration of anesthesia, see modifiers 73 and 74 (see modifiers approved for asc hospital outpatient use). | 59 | Distinct procedural service: under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-e/m services performed on the same day. modifier 59 is used to identify procedures/services, other than e/m services, that are not normally reported together, but are appropriate under the circumstances. documentation must support a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual. however, when another already established modifier is appropriate it should be used rather than modifier 59. only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used. note: modifier 59 should not be appended to an e/m service. to report a separate and distinct e/m service with a non-e/m service performed on the same date, see modifier 25. | GC | This service has been performed in part by a resident under the direction of a teaching physician | LT | Left side (used to identify procedures performed on the left side of the body) | RT | Right side (used to identify procedures performed on the right side of the body) | XS | Separate structure, a service that is distinct because it was performed on a separate organ/structure |
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| Pre-1990 | Added | Code added. |
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