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The CPT® Code 28262 refers to a surgical procedure known as a capsulotomy of the midfoot, which is extensive in nature. This procedure involves making an incision in the fibrous covering, or capsule, of the ankle joint, specifically on the inward side. The primary purpose of this intervention is to address conditions such as resistant clubfoot deformity, where the foot tends to twist inward. By performing a capsulotomy, the physician aims to alleviate the tightness and restriction caused by the fibrous tissue, allowing for better alignment and function of the foot. In addition to the capsulotomy, this procedure may also include the lengthening of tendons that are contributing to the deformity. It is important to note that if the procedure requires incisions on multiple sides of the ankle joint and involves lengthening several tendons, the appropriate code to use is 28262. This code is distinct from CPT® Code 28261, which is used when only the tendons on the inward side of the ankle are lengthened without the extensive capsulotomy. Understanding the specific indications and procedural details associated with CPT® Code 28262 is crucial for accurate medical coding and billing practices.
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The procedure associated with CPT® Code 28262 is indicated for specific conditions that necessitate surgical intervention to correct foot deformities. The primary indication for this extensive capsulotomy is resistant clubfoot deformity, a condition where the foot is twisted inward and may not respond adequately to conservative treatments. This deformity can lead to difficulties in walking and overall mobility if not addressed. The procedure is performed when there is a need to release the tension in the fibrous capsule of the ankle joint and to lengthen multiple tendons that contribute to the inward twisting of the foot.
The procedure for CPT® Code 28262 involves several critical steps to ensure effective correction of the foot deformity. First, the surgeon makes an incision on the inward side of the ankle joint to access the fibrous capsule. This incision allows the surgeon to visualize and evaluate the extent of the deformity and the surrounding structures. Next, the surgeon performs an extensive capsulotomy, which involves cutting through the fibrous capsule to release the tension that is causing the foot to twist inward. This step is crucial for restoring proper alignment of the foot. Following the capsulotomy, the surgeon may proceed to lengthen multiple tendons that are contributing to the deformity. This lengthening is essential to provide the necessary flexibility and range of motion to the foot, preventing it from reverting to its twisted position. The procedure may involve careful dissection and manipulation of the tendons to achieve the desired lengthening. Finally, the surgeon will close the incisions with sutures, ensuring that the area is properly secured for healing.
After the completion of the procedure associated with CPT® Code 28262, post-operative care is essential for optimal recovery. Patients are typically monitored for any immediate complications following surgery. Pain management is an important aspect of post-procedure care, and patients may be prescribed analgesics to manage discomfort. Additionally, the foot may be immobilized using a cast or splint to ensure stability during the healing process. Physical therapy may be recommended to aid in rehabilitation and to improve mobility as the patient recovers. Follow-up appointments are crucial to assess the healing progress and to determine if any further interventions are necessary. Patients should be advised on signs of infection or complications that may require immediate medical attention.
| Short Descr | REVISION OF FOOT AND ANKLE | Medium Descr | CAPSUL MIDFOOT W/PST TALOTIBL CAPSUL&TDN LNGTH | Long Descr | Capsulotomy, midfoot; extensive, including posterior talotibial capsulotomy and tendon(s) lengthening (eg, resistant clubfoot deformity) | 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 | Device-intensive procedure added to ASC list in CY 2008 or later; paid at adjusted rate. | Type of Service (TOS) | 2 - Surgery | Berenson-Eggers TOS (BETOS) | P3D - Major procedure, orthopedic - other | MUE | 1 | CCS Clinical Classification | 150 - Division of joint capsule, ligament or cartilage |
| 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. | 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. | 80 | Assistant surgeon: surgical assistant services may be identified by adding modifier 80 to the usual procedure number(s). | 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) | 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 | 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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