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The procedure described by CPT® Code 27620 refers to an arthrotomy of the ankle, which involves making an incision to access the ankle joint for exploration. This procedure is performed to evaluate various conditions affecting the joint, such as injuries, diseases, or infections. The approach taken during the surgery is tailored to the specific condition suspected by the physician. Initially, a skin incision is made, and the surgeon carefully dissects through the soft tissues, ensuring the protection of nearby nerves and blood vessels. Once the ankle joint capsule is reached, it is incised to allow for direct inspection of the joint interior. During this exploration, the surgeon looks for signs of damage, disease processes, or infection. If necessary, tissue samples may be collected for laboratory analysis, which can be reported separately. Additionally, if any loose or foreign bodies are identified within the joint, they are removed to alleviate potential complications. After the exploration and any necessary interventions, the joint is typically flushed with saline to clear out any debris. Finally, the joint capsule is closed, followed by a layered closure of the surrounding soft tissues and skin to ensure proper healing and minimize scarring.
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The arthrotomy of the ankle, as described by CPT® Code 27620, is indicated for various conditions that necessitate direct visualization and intervention within the ankle joint. The following are specific indications for this procedure:
The arthrotomy procedure involves several critical steps to ensure thorough exploration and treatment of the ankle joint. The following outlines the procedural steps involved:
Post-procedure care following an arthrotomy of the ankle is essential for recovery. Patients are typically monitored for any signs of complications, such as infection or excessive swelling. Pain management is also an important aspect of post-operative care, and patients may be prescribed analgesics as needed. Rehabilitation may be initiated to restore mobility and strength in the ankle joint, depending on the specific interventions performed during the procedure. Follow-up appointments are crucial to assess healing and to determine if any further treatment is necessary. Patients are advised to follow their surgeon's instructions regarding activity restrictions and care of the surgical site to ensure a successful recovery.
| Short Descr | EXPLORE/TREAT ANKLE JOINT | Medium Descr | ARTHRT ANKLE W/EXPL W/WO BX W/WO RMVL LOOSE/FB | Long Descr | Arthrotomy, ankle, 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) | 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 | 159 - Other diagnostic procedures on musculoskeletal system |
| 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). | 54 | Surgical care only: when 1 physician or other qualified health care professional performs a surgical procedure and another provides preoperative and/or postoperative management, surgical services may be identified by adding modifier 54 to the usual procedure number. | 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). | 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). | AS | Physician assistant, nurse practitioner, or clinical nurse specialist services for assistant at surgery | ET | Emergency services | F2 | Left hand, third digit | F3 | Left hand, fourth digit | F4 | Left hand, fifth digit | F7 | Right hand, third digit | 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 | XE | Separate encounter, a service that is distinct because it occurred during a separate encounter | 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. |
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