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Official Description

Capsulotomy, posterior capsular release, knee

© Copyright 2025 American Medical Association. All rights reserved.

Common Language Description

A capsulotomy with posterior capsular release is a surgical procedure performed on the knee joint, primarily aimed at addressing flexion contracture, a condition where the knee cannot fully extend due to tightness or shortening of the surrounding soft tissues. During this procedure, a surgical incision is made over the posteromedial aspect of the knee, which is the back and inner side of the joint. This approach allows the surgeon to access the joint capsule, which is a fibrous tissue structure that encases the knee joint. Once the joint capsule is exposed, it is incised to facilitate further intervention. The procedure involves the excision of scar tissue that may be contributing to the contracture, followed by the detachment of the posterior capsule from the femur, the thigh bone that forms part of the knee joint. After the necessary surgical corrections are made, the range of motion of the knee is assessed to ensure that the desired mobility is achieved. Finally, the incisions are closed in layers to promote proper healing, and a cast may be applied if necessary to maintain the knee in an extended position during the recovery phase.

© Copyright 2025 Coding Ahead. All rights reserved.

1. Indications

The procedure of capsulotomy with posterior capsular release is indicated for specific conditions related to knee mobility and function. The following are the primary indications for performing this surgical intervention:

  • Flexion Contracture - This condition is characterized by the inability to fully extend the knee due to tightness in the surrounding soft tissues, which may include the joint capsule and ligaments.

2. Procedure

The capsulotomy with posterior capsular release involves several critical procedural steps that ensure effective treatment of the flexion contracture. Each step is essential for achieving the desired outcome of improved knee mobility.

  • Step 1: Incision - The procedure begins with the surgeon making an incision over the posteromedial aspect of the knee. This specific location is chosen to provide optimal access to the joint capsule while minimizing damage to surrounding structures.
  • Step 2: Exposure of the Joint Capsule - After the incision is made, the surgeon carefully dissects through the subcutaneous tissue to expose the joint capsule. This step is crucial as it allows for direct access to the area that requires intervention.
  • Step 3: Incision of the Joint Capsule - Once the joint capsule is exposed, the surgeon incises it to facilitate further surgical manipulation. This incision is necessary to relieve the tension caused by the contracted tissues.
  • Step 4: Excision of Scar Tissue - The next step involves the excision of any scar tissue that may be present within the joint capsule. This scar tissue can contribute to the flexion contracture and must be removed to restore normal function.
  • Step 5: Detachment of the Posterior Capsule - Following the excision of scar tissue, the posterior capsule is detached from the femur. This detachment is critical for allowing the knee to achieve a greater range of motion.
  • Step 6: Range of Motion Assessment - After the surgical corrections are made, the surgeon checks the range of motion of the knee to ensure that the procedure has successfully addressed the flexion contracture.
  • Step 7: Closure of Incisions - Finally, the incisions made during the procedure are closed in layers. This layered closure technique is important for promoting optimal healing and minimizing the risk of complications.
  • Step 8: Application of Cast - In some cases, a cast may be applied to maintain the knee in an extended position post-surgery. This helps to support the healing process and prevent re-contracture of the knee.

3. Post-Procedure

Post-procedure care following a capsulotomy with posterior capsular release is essential for ensuring proper recovery and rehabilitation. Patients may be monitored for any signs of complications, and pain management strategies will be implemented as needed. The application of a cast, if utilized, will help maintain the knee in extension during the initial healing phase. Physical therapy may be recommended to assist in regaining strength and mobility in the knee joint. Patients should follow their surgeon's specific instructions regarding activity restrictions and rehabilitation exercises to optimize recovery outcomes.

Short Descr INCISION OF KNEE JOINT
Medium Descr CAPSULOTOMY POSTERIOR CAPSULAR RELEASE KNEE
Long Descr Capsulotomy, posterior capsular release, knee
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) 1 - Co-surgeons could be paid, though supporting documentation is required...
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
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.
RT Right side (used to identify procedures performed on the right side of the body)
LT Left side (used to identify procedures performed on the left side of the body)
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).
AS Physician assistant, nurse practitioner, or clinical nurse specialist services for assistant at surgery
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.
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).
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.
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).
GC This service has been performed in part by a resident under the direction of a teaching physician
GW Service not related to the hospice patient's terminal condition
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
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Pre-1990 Added Code added.
1985-12-31 Deleted Code deleted.
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