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The procedure described by CPT® Code 28054 refers to an arthrotomy with biopsy specifically targeting the interphalangeal joint. The interphalangeal joints are the hinge joints located between the phalanges of the fingers and toes, allowing for flexion and extension. This procedure involves making an incision to access the joint space, which is crucial for obtaining tissue samples for diagnostic purposes. The term 'arthrotomy' indicates that the joint capsule is surgically opened, allowing the physician to directly visualize and access the joint structures. During the biopsy, tissue samples are collected from the joint for further laboratory analysis, which can help in diagnosing various conditions affecting the joint. The procedure concludes with the careful closure of the incision in layers to promote optimal healing, followed by the application of a dressing to protect the surgical site. It is important to note that this code is specifically designated for biopsies of the proximal or distal interphalangeal joints, distinguishing it from similar procedures performed on other joints, such as the intertarsal or tarsometatarsal joints, which are coded differently (CPT® Codes 28050 and 28052, respectively).
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The arthrotomy with biopsy of the interphalangeal joint, as described by CPT® Code 28054, is indicated for various clinical scenarios where a detailed examination of the joint tissue is necessary. The following conditions may warrant this procedure:
The procedure for an arthrotomy with biopsy of the interphalangeal joint involves several critical steps to ensure proper access and tissue sampling. The following outlines the procedural steps:
Following the arthrotomy with biopsy of the interphalangeal joint, patients can expect specific post-procedure care and considerations. It is essential to monitor the surgical site for any signs of infection, such as increased redness, swelling, or discharge. Pain management may be necessary, and patients are typically advised to rest the affected joint to promote healing. Follow-up appointments may be scheduled to review biopsy results and assess recovery progress. Patients should also be instructed on proper wound care and any activity restrictions to ensure optimal recovery.
| Short Descr | BIOPSY OF TOE JOINT LINING | Medium Descr | ARTHRTOMY W/BX INTERPHALANGEAL JOINT | Long Descr | Arthrotomy with biopsy; interphalangeal joint | 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) | 0 - 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 | 2 | 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). | 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.) | AS | Physician assistant, nurse practitioner, or clinical nurse specialist services for assistant at surgery | 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) | T1 | Left foot, second digit | T2 | Left foot, third digit | T3 | Left foot, fourth digit | T5 | Right foot, great toe | T6 | Right foot, second digit | T7 | Right foot, third digit | T8 | Right foot, fourth digit | T9 | Right foot, fifth digit | TA | Left foot, great toe |
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| Pre-1990 | Added | Code added. |
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