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Decompression fasciotomy is a surgical procedure aimed at alleviating the pressure within a muscle compartment, which is critical in treating compartment syndrome. Compartment syndrome occurs when swelling within a muscle compartment leads to increased pressure that can compress blood vessels and nerves, potentially resulting in irreversible damage to the muscles and nerves if not addressed promptly. The muscle compartments are encased in fascia, a dense connective tissue that does not stretch, thus any swelling can lead to significant complications. In the thigh and knee region, there are three distinct compartments: the flexor, extensor, and adductor compartments. The CPT® Code 27496 specifically refers to the decompression of one of these compartments, either the flexor, extensor, or adductor, without the need for debridement of nonviable tissue. The procedure involves making a precise incision over the lateral aspect of the thigh, allowing access to the affected compartment. This intervention is crucial for restoring blood flow and preventing long-term damage to the muscle and nerve structures within the compartment.
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The decompression fasciotomy procedure, coded as CPT® 27496, is indicated for the treatment of compartment syndrome, which can arise from various conditions leading to increased pressure within a muscle compartment. The following are specific indications for performing this procedure:
The procedure for decompression fasciotomy involves several critical steps to ensure effective treatment of the affected compartment. Each step is detailed as follows:
After the decompression fasciotomy, the patient is monitored closely for signs of improvement in compartment pressures and overall recovery. The incisions are left open to allow for any residual swelling to decrease, and they are covered with appropriate dressings to protect the surgical site. Once the swelling has subsided, typically within 24 to 72 hours, the patient is scheduled to return to the operating room for definitive wound closure. It is essential to monitor the patient for any complications, such as infection or delayed healing, during the recovery period.
| Short Descr | DECOMPRESSION OF THIGH/KNEE | Medium Descr | DECOMPRESSION FASCIOTOMY THIGH&/KNEE 1 COMPONENT | Long Descr | Decompression fasciotomy, thigh and/or knee, 1 compartment (flexor or extensor or adductor); | 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) | 1 - Statutory 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) | P3D - Major procedure, orthopedic - other | MUE | 1 | CCS Clinical Classification | 160 - Other therapeutic procedures on muscles and tendons |
| 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. | 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.) | 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 | CC | Procedure code change (use 'cc' when the procedure code submitted was changed either for administrative reasons or because an incorrect code was filed) | 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) |
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| 2010-01-01 | Changed | Code description changed. |
| 1993-01-01 | Added | First appearance in code book in 1993. |
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