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Official Description

Costotransversectomy (separate procedure)

© Copyright 2025 American Medical Association. All rights reserved.

Common Language Description

The procedure described by CPT® Code 21610 refers to a costotransversectomy, which is classified as a separate surgical procedure. In this operation, the physician makes an incision above the costovertebral joint, which is the joint connecting the rib to the vertebra. The purpose of this incision is to access the underlying structures. During the procedure, the physician carefully resects, or removes, tissue to expose the joint for better visualization. This step is crucial for ensuring that the subsequent surgical actions can be performed accurately and safely. Following the visualization of the joint, the transverse process, a bony projection off the vertebra, is excised from the vertebral body. Additionally, a portion of the adjacent rib is also removed to facilitate the procedure. Once the necessary surgical interventions are completed, all incisions made during the operation are meticulously closed to promote proper healing and minimize complications. This procedure is typically indicated in specific clinical scenarios where access to the costovertebral joint is necessary for further treatment or intervention.

© Copyright 2025 Coding Ahead. All rights reserved.

1. Indications

Costotransversectomy (CPT® Code 21610) is performed for specific indications that necessitate surgical intervention at the costovertebral joint. The following conditions may warrant this procedure:

  • Spinal Tumors The presence of tumors affecting the vertebrae or surrounding structures may require resection to alleviate symptoms or prevent further complications.
  • Infections Infections in the area surrounding the costovertebral joint may necessitate surgical intervention to remove infected tissue and prevent the spread of infection.
  • Trauma Injuries to the spine that involve the costovertebral joint may require surgical access for repair or stabilization.
  • Chronic Pain Patients experiencing chronic pain related to the costovertebral joint may be candidates for this procedure if conservative treatments have failed.

2. Procedure

The costotransversectomy procedure involves several critical steps to ensure effective surgical intervention. The following outlines the procedural steps involved:

  • Step 1: Incision The surgeon begins by making a precise incision above the costovertebral joint. This incision is strategically placed to provide optimal access to the underlying anatomical structures while minimizing damage to surrounding tissues.
  • Step 2: Tissue Resection After the incision is made, the physician carefully resects tissue to expose the costovertebral joint. This step is essential for visualizing the joint and surrounding structures, allowing the surgeon to assess the area for any abnormalities or pathologies.
  • Step 3: Removal of Transverse Process Once the joint is adequately visualized, the surgeon proceeds to remove the transverse process from the vertebral body. This bony structure is excised to facilitate further surgical intervention and to provide access to the joint.
  • Step 4: Resection of Adjacent Rib In conjunction with the removal of the transverse process, a portion of the adjacent rib is also excised. This step is necessary to ensure that the surgical field is clear and to allow for any additional procedures that may be required.
  • Step 5: Closure of Incisions After completing the necessary surgical interventions, the surgeon meticulously closes all incisions. This closure is performed to promote healing and reduce the risk of postoperative complications.

3. Post-Procedure

Following a costotransversectomy, patients may require specific post-procedure care to ensure optimal recovery. It is essential to monitor the surgical site for any signs of infection or complications. Patients are typically advised to follow up with their healthcare provider for assessments of healing and to manage any postoperative pain. Rehabilitation may be recommended to restore mobility and strength in the affected area. The expected recovery time can vary based on individual patient factors and the extent of the procedure performed.

Short Descr PARTIAL REMOVAL OF RIB
Medium Descr COSTOTRANSVERSECTOMY SEPARATE PROCEDURE
Long Descr Costotransversectomy (separate procedure)
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) 0 - 150% payment adjustment for bilateral procedures does NOT apply.
Physician Supervisions 09 - Concept does not apply.
Assistant Surgeon (80, 82) 2 - Payment restriction for assistants at surgery does not apply 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 142 - Partial excision bone
22 Increased procedural services: when the work required to provide a service is substantially greater than typically required, it may be identified by adding modifier 22 to the usual procedure code. documentation must support the substantial additional work and the reason for the additional work (ie, increased intensity, time, technical difficulty of procedure, severity of patient's condition, physical and mental effort required). note: this modifier should not be appended to an e/m service.
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).
58 Staged or related procedure or service by the same physician or other qualified health care professional during the postoperative period: it may be necessary to indicate that the performance of a procedure or service during the postoperative period was: (a) planned or anticipated (staged); (b) more extensive than the original procedure; or (c) for therapy following a surgical procedure. this circumstance may be reported by adding modifier 58 to the staged or related procedure. note: for treatment of a problem that requires a return to the operating/procedure room (eg, unanticipated clinical condition), see modifier 78.
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.
79 Unrelated procedure or service by the same physician or other qualified health care professional during the postoperative period: the individual may need to indicate that the performance of a procedure or service during the postoperative period was unrelated to the original procedure. this circumstance may be reported by using modifier 79. (for repeat procedures on the same day, see modifier 76.)
80 Assistant surgeon: surgical assistant services may be identified by adding modifier 80 to the usual procedure number(s).
82 Assistant surgeon (when qualified resident surgeon not available): the unavailability of a qualified resident surgeon is a prerequisite for use of modifier 82 appended to the usual procedure code number(s).
AS Physician assistant, nurse practitioner, or clinical nurse specialist services for assistant at surgery
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)
XU Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service
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