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Official Description

Arthrotomy, elbow; with joint exploration, with or without biopsy, with or without removal of loose or foreign body

© Copyright 2025 American Medical Association. All rights reserved.

Common Language Description

The procedure described by CPT® Code 24101 refers to an arthrotomy of the elbow, which is a surgical operation involving the opening of the elbow joint capsule. This procedure is performed for various reasons, including joint exploration, obtaining biopsies, and the removal of loose or foreign bodies within the joint. The term 'arthrotomy' indicates that the joint is surgically accessed, allowing the physician to directly visualize and manipulate the internal structures of the elbow joint. The elbow joint capsule can be approached through different surgical techniques, such as posterior, medial, or anterolateral approaches, depending on the specific needs of the procedure. During the arthrotomy, the physician may perform a synovial biopsy, which involves taking samples of the synovial tissue for laboratory analysis. Additionally, the procedure may include the exploration of the joint to identify and address any abnormalities, such as osteophytes (bone spurs) or loose bodies that may be causing pain or limiting function. The ulnar nerve, which runs near the elbow joint, is also identified and decompressed if necessary to alleviate any nerve-related symptoms. Overall, CPT® Code 24101 encompasses a comprehensive approach to diagnosing and treating various conditions affecting the elbow joint through surgical intervention.

© Copyright 2025 Coding Ahead. All rights reserved.

1. Indications

The procedure described by CPT® Code 24101 is indicated for various conditions affecting the elbow joint. These include:

  • Joint Pain Persistent pain in the elbow that may be due to underlying joint pathology.
  • Joint Swelling Swelling in the elbow joint that may indicate inflammation or the presence of loose bodies.
  • Limited Range of Motion Difficulty in moving the elbow joint fully, which may be caused by mechanical obstruction or joint disease.
  • Suspected Joint Pathology Conditions such as arthritis or other degenerative diseases that require direct visualization and assessment.
  • Presence of Loose or Foreign Bodies Identification and removal of loose fragments or foreign objects within the joint that may cause pain or dysfunction.

2. Procedure

The procedure for CPT® Code 24101 involves several key steps that ensure thorough exploration and treatment of the elbow joint. Each step is critical for achieving the desired outcomes.

  • Step 1: Joint Capsule Opening The surgeon begins by making an incision to open the elbow joint capsule. This can be done using a posterior, medial, or anterolateral approach, depending on the specific area of concern and the surgeon's preference.
  • Step 2: Joint Exploration Once the joint capsule is opened, the surgeon explores the interior of the elbow joint. This exploration allows for the assessment of the joint's condition and the identification of any abnormalities, such as osteophytes or loose bodies.
  • Step 3: Biopsy Collection If necessary, biopsies of the synovial tissue are obtained during the exploration. These samples are sent for separately reportable laboratory analysis to evaluate for any pathological conditions.
  • Step 4: Ulnar Nerve Management The ulnar nerve is identified during the procedure. If there is evidence of compression or irritation, the surgeon may decompress the nerve to alleviate symptoms and prevent further complications.
  • Step 5: Removal of Osteophytes and Loose Bodies Any osteophytes (bone spurs) present in the joint are removed using an osteotome. Additionally, any loose or foreign bodies identified during the exploration are also extracted to restore normal joint function.
  • Step 6: Irrigation and Closure After completing the necessary interventions, the joint is irrigated with saline solution to clear any debris. The incisions are then closed, ensuring proper healing and recovery.

3. Post-Procedure

Following the arthrotomy of the elbow, patients can expect a recovery period that may involve pain management and rehabilitation. Post-procedure care typically includes monitoring for signs of infection, managing pain with prescribed medications, and following a rehabilitation program to restore range of motion and strength in the elbow. Patients are advised to avoid strenuous activities during the initial recovery phase and to follow up with their healthcare provider for assessment and guidance on resuming normal activities.

Short Descr ARTHRT ELBW JT EXPL BX RMVL
Medium Descr ARTHRT ELBOW W/JT EXPL W/WOBX W/O RMVL LOOSE/FB
Long Descr Arthrotomy, elbow; with joint exploration, with or without biopsy, with or without removal of loose or foreign body
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) 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 159 - Other diagnostic procedures on musculoskeletal system
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.
76 Repeat procedure or service by same physician or other qualified health care professional: it may be necessary to indicate that a procedure or service was repeated by the same physician or other qualified health care professional subsequent to the original procedure or service. this circumstance may be reported by adding modifier 76 to the repeated procedure or service. note: this modifier should not be appended to an e/m service.
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).
81 Minimum assistant surgeon: minimum surgical assistant services are identified by adding modifier 81 to the usual procedure number.
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).
AQ Physician providing a service in an unlisted health professional shortage area (hpsa)
AS Physician assistant, nurse practitioner, or clinical nurse specialist services for assistant at surgery
CG Policy criteria applied
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
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2023-01-01 Note Short and medium descriptions changed.
Pre-1990 Added Code added.
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