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The procedure described by CPT® Code 27612 refers to an arthrotomy involving a posterior capsular release of the ankle, which may also include the lengthening of the Achilles tendon. This surgical intervention is typically indicated when the ligaments surrounding the ankle joint are excessively tight or when there is a congenital deformity, such as clubfoot, that affects the normal function and alignment of the foot and ankle. The joint capsule, which is a fibrous structure that encases the joint and provides stability, may need to be incised to alleviate tension and improve mobility. During the procedure, a posterior approach is utilized, allowing the surgeon to carefully dissect the surrounding tissues to access the joint capsule. Once exposed, the posterior ligaments and the joint capsule are incised, which facilitates an increase in the range of motion and addresses any existing malformations. Additionally, the Achilles tendon may be lengthened through techniques such as Z-plasty or longitudinal incisions, which are designed to enhance flexibility and function. After the surgical intervention, the foot is typically immobilized in a cast to ensure it remains in a more anatomically correct position, aiding in the healing process and preserving the length of the ligaments and Achilles tendon.
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The procedure described by CPT® Code 27612 is indicated for specific conditions that necessitate surgical intervention to improve ankle function and alignment. The following are the primary indications for performing this procedure:
The surgical procedure for CPT® Code 27612 involves several critical steps to achieve the desired outcome. Each step is essential for ensuring the successful release of the posterior capsule and any necessary tendon lengthening.
After the completion of the procedure, post-operative care is essential for optimal recovery. The patient will typically be required to keep the foot immobilized in a cast for a specified period to ensure proper healing and alignment. During this time, the patient may need to follow specific instructions regarding weight-bearing activities and rehabilitation exercises. Regular follow-up appointments will be necessary to monitor the healing process and assess the range of motion in the ankle. Any signs of complications, such as infection or excessive swelling, should be reported to the healthcare provider promptly to ensure timely intervention.
| Short Descr | EXPLORATION OF ANKLE JOINT | Medium Descr | ARTHRT PST CAPSUL RLS ANKLE W/WO ACHLL TDN LNGTH | Long Descr | Arthrotomy, posterior capsular release, ankle, with or without Achilles tendon lengthening | 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) | P5B - Ambulatory procedures - musculoskeletal | MUE | 1 | CCS Clinical Classification | 150 - Division of joint capsule, ligament or cartilage |
| 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). | XU | Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service | 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). | 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.) | 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). | 99 | Multiple modifiers: under certain circumstances 2 or more modifiers may be necessary to completely delineate a service. in such situations modifier 99 should be added to the basic procedure, and other applicable modifiers may be listed as part of the description of the service. | 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 |
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