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Official Description

Arthrotomy of the elbow, with capsular excision for capsular release (separate procedure)

© Copyright 2025 American Medical Association. All rights reserved.

Common Language Description

Arthrotomy of the elbow with capsular excision for capsular release is a surgical procedure aimed at addressing capsular contracture of the elbow joint. This condition involves the tightening or shortening of the joint capsule, which can restrict movement and cause pain. The procedure involves making an incision to access the joint capsule, allowing the surgeon to excise the contracted tissue. The approach taken—whether posterior, posterolateral, medial, or anterolateral—depends on the specific location and nature of the contracture. By carefully exposing the joint capsule, the surgeon can effectively release the tension, thereby restoring range of motion and alleviating discomfort. The procedure is classified as a separate procedure, indicating that it is performed independently and is not part of a more extensive surgical intervention. This detailed approach ensures that the underlying issues contributing to the capsular contracture are addressed, facilitating improved joint function and patient outcomes.

© Copyright 2025 Coding Ahead. All rights reserved.

1. Indications

Arthrotomy of the elbow with capsular excision for capsular release is indicated for the following conditions:

  • Capsular Contracture - This procedure is primarily performed to treat capsular contracture of the elbow joint, which results in restricted movement and discomfort.

2. Procedure

The procedure involves several critical steps to ensure effective treatment of the capsular contracture:

  • Step 1: Incision - A proximal incision is made from the lateral supracondylar ridge to the lateral epicondyle, extending distally in a curvilinear fashion to the posterior border of the ulna. This incision allows for adequate exposure of the joint capsule.
  • Step 2: Exposure of the Joint Capsule - The anterior musculature is carefully stripped away to expose the anterior capsule. The extensor carpi radialis longus (ECRL) is retracted and elevated off the lateral epicondyle to facilitate access to the joint capsule.
  • Step 3: Elevation of Muscles - The ECRL, along with the brachioradialis and brachialis muscles, is elevated off the joint capsule to provide a clear view and access to the area requiring intervention.
  • Step 4: Identification of Key Structures - The lateral collateral ligament (LCL) and ulnar nerve are identified and protected during the procedure to prevent any damage to these critical structures.
  • Step 5: Dissection of the Common Extensor Tendon - The common extensor tendon is dissected off the LCL and joint capsule, allowing for further access to the contracted capsule.
  • Step 6: Incision and Excision of the Capsule - The joint capsule is incised and elevated, and the contracted portion is excised to relieve the capsular contracture.
  • Step 7: Evaluation of Range of Motion - The range of motion is evaluated by flexing and extending the joint and turning the palm up and down to assess the effectiveness of the release.
  • Step 8: Additional Dissection - If necessary, additional dissection is performed to free any adhesions that may be compromising mobility, ensuring optimal joint function post-procedure.
  • Step 9: Wound Repair - Following the release of the capsular contracture, the surgical wound is repaired in layers, and dressings are applied to promote healing.

3. Post-Procedure

After the procedure, patients can expect a recovery period that may involve pain management and physical therapy to restore full range of motion. The surgical site will be monitored for signs of infection or complications, and follow-up appointments will be scheduled to assess healing and functional recovery. Patients are typically advised on activity restrictions to ensure proper healing and to avoid re-injury to the elbow joint.

Short Descr ARTHRT ELBW CAPSL EXC RLS
Medium Descr ARTHRT ELBOW CAPSULAR EXCISION CAPSULAR RLS SPX
Long Descr Arthrotomy of the elbow, with capsular excision for capsular release (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) 1 - 150% payment adjustment for bilateral procedures applies.
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) 2 - Co-surgeons permitted and no documentation required if the two- specialty requirement is met.
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) P3D - Major procedure, orthopedic - other
MUE 1
CCS Clinical Classification 150 - Division of joint capsule, ligament or cartilage
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.
62 Two surgeons: when 2 surgeons work together as primary surgeons performing distinct part(s) of a procedure, each surgeon should report his/her distinct operative work by adding modifier 62 to the procedure code and any associated add-on code(s) for that procedure as long as both surgeons continue to work together as primary surgeons. each surgeon should report the co-surgery once using the same procedure code. if additional procedure(s) (including add-on procedure(s) are performed during the same surgical session, separate code(s) may also be reported with modifier 62 added. note: if a co-surgeon acts as an assistant in the performance of additional procedure(s), other than those reported with the modifier 62, during the same surgical session, those services may be reported using separate procedure code(s) with modifier 80 or modifier 82 added, as appropriate.
78 Unplanned return to the operating/procedure room by the same physician or other qualified health care professional following initial procedure for a related procedure during the postoperative period: it may be necessary to indicate that another procedure was performed during the postoperative period of the initial procedure (unplanned procedure following initial procedure). when this procedure is related to the first, and requires the use of an operating/procedure room, it may be reported by adding modifier 78 to the related procedure. (for repeat procedures, see modifier 76.)
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).
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)
SG Ambulatory surgical center (asc) facility service
XS Separate structure, a service that is distinct because it was performed on a separate organ/structure
XU Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service
Date
Action
Notes
2023-01-01 Note Short description changed.
1993-01-01 Added First appearance in code book in 1993.
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