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The CPT® Code 28260 refers to a surgical procedure known as a capsulotomy of the midfoot, specifically involving a medial release only. This procedure is classified as a separate procedure, indicating that it is performed independently and is not part of a more comprehensive surgical intervention. During the capsulotomy, the physician makes a precise incision on the medial, or inward, side of the fibrous capsule that encases the ankle joint. This surgical approach is primarily aimed at addressing conditions such as clubfoot, where the foot tends to twist inward, leading to functional and aesthetic concerns. By performing this procedure, the physician aims to correct the alignment of the foot, thereby preventing further complications associated with the twisting motion. It is important to note that if additional procedures are required, such as lengthening the tendons on the inward side of the ankle, the appropriate codes (CPT® 28261 or CPT® 28262) should be utilized to accurately reflect the extent of the surgical intervention.
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The procedure described by CPT® Code 28260 is indicated for specific conditions that affect the alignment and function of the foot. The primary indication for performing a medial release capsulotomy is to correct clubfoot, a congenital deformity characterized by an inward twisting of the foot. This condition can lead to difficulties in walking and other functional impairments if not addressed. The procedure may also be indicated in cases where there is a need to relieve tension in the fibrous covering of the ankle joint, thereby improving mobility and alignment.
The capsulotomy procedure involves several key steps to ensure effective correction of the foot's alignment. First, the physician prepares the surgical site by cleaning and sterilizing the area around the ankle joint. Following this, an incision is made on the medial side of the foot, specifically targeting the fibrous capsule that surrounds the ankle joint. This incision allows access to the underlying structures, enabling the physician to perform the necessary release of the fibrous tissue. The surgeon carefully dissects the tissue to avoid damaging surrounding nerves and blood vessels. Once the medial release is completed, the physician assesses the alignment of the foot to ensure that the correction has been achieved. Finally, the incision is closed using sutures, and the area is bandaged to promote healing.
After the capsulotomy procedure, patients are typically monitored for any immediate complications. Post-procedure care may include instructions for rest and elevation of the foot to reduce swelling. Patients may also be advised to avoid putting weight on the affected foot for a specified period to allow for proper healing. Follow-up appointments are essential to assess the recovery process and to ensure that the foot maintains its corrected alignment. Physical therapy may be recommended to strengthen the foot and improve mobility as healing progresses. It is crucial for patients to adhere to the post-operative care instructions provided by their healthcare provider to achieve optimal outcomes.
| Short Descr | RELEASE OF MIDFOOT JOINT | Medium Descr | CAPSULOTOMY MIDFOOT MEDIAL RELEASE ONLY SPX | Long Descr | Capsulotomy, midfoot; medial release only (separate procedure) | 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 |
| 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). | RT | Right side (used to identify procedures performed on the right side of the body) | 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. | 62 | Two surgeons: when 2 surgeons work together as primary surgeons performing distinct part(s) of a procedure, each surgeon should report his/her distinct operative work by adding modifier 62 to the procedure code and any associated add-on code(s) for that procedure as long as both surgeons continue to work together as primary surgeons. each surgeon should report the co-surgery once using the same procedure code. if additional procedure(s) (including add-on procedure(s) are performed during the same surgical session, separate code(s) may also be reported with modifier 62 added. note: if a co-surgeon acts as an assistant in the performance of additional procedure(s), other than those reported with the modifier 62, during the same surgical session, those services may be reported using separate procedure code(s) with modifier 80 or modifier 82 added, as appropriate. | 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 | 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) | T1 | Left foot, second digit | T5 | Right foot, great toe | T6 | Right foot, second digit | TA | Left foot, great toe | 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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