© Copyright 2025 American Medical Association. All rights reserved.
Surgical arthroscopy of the ankle, specifically involving the tibiotalar and fibulotalar joints, is a minimally invasive procedure that allows for direct visualization and intervention within the ankle joint. This procedure is performed in conjunction with ankle arthrodesis, commonly known as ankle fusion, which is a surgical technique aimed at stabilizing the ankle joint by fusing the bones together. Ankle instability, which may arise from various conditions such as severe arthritis, trauma, or chronic ligamentous injuries, can lead to significant pain and functional impairment. The surgical approach begins with the careful positioning of the leg on an L-shaped bar, ensuring that the thigh is supported while allowing the lower leg to move freely. This positioning facilitates access to the ankle joint. The procedure involves the use of a saline solution to inflate the joint, which aids in the creation of a working space for the surgeon. Through the insertion of a trocar and an arthroscope, the surgeon can inspect the joint for any pathological changes, including injury, disease, or signs of infection. The subsequent steps involve the removal of damaged tissue and bone spurs, ultimately preparing the joint for fusion. This comprehensive approach not only addresses the immediate concerns of joint instability but also aims to restore function and alleviate pain for the patient.
© Copyright 2025 Coding Ahead. All rights reserved.
The procedure is indicated for patients experiencing significant ankle instability, which may be due to various underlying conditions. The following are specific indications for performing this surgical arthroscopy with ankle arthrodesis:
The surgical procedure involves several critical steps to ensure effective treatment of the ankle joint. The following outlines the procedural steps:
After the completion of the surgical procedure, patients can expect a recovery period that may involve pain management and rehabilitation. Post-operative care typically includes monitoring for any signs of infection or complications. Patients are often advised to follow a specific rehabilitation protocol to gradually restore mobility and strength to the ankle joint. The duration of recovery may vary based on individual factors, including the extent of the procedure and the patient's overall health. It is essential for patients to adhere to follow-up appointments to ensure proper healing and to assess the success of the ankle fusion.
| Short Descr | ANKLE ARTHROSCOPY/SURGERY | Medium Descr | ARTHROSCOPY ANKLE SURGICAL W/ANKLE ARTHRODESIS | Long Descr | Arthroscopy, ankle (tibiotalar and fibulotalar joints), surgical; with ankle arthrodesis | 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) | P8A - Endoscopy - arthroscopy | MUE | 1 | CCS Clinical Classification | 162 - Other OR therapeutic procedures on joints |
| 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. | 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). | 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 |
|
Date
|
Action
|
Notes
|
|---|---|---|
| 2003-01-01 | Added | First appearance in code book in 2003. |
Get instant expert-level medical coding assistance.