How To Use CPT Code 27005

CPT 27005 describes the surgical procedure known as tenotomy, specifically the open division of one or more hip flexor muscles. This article will provide an overview of CPT code 27005, including its official description, the procedure itself, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples.

1. What is CPT Code 27005?

CPT 27005 is used to describe a surgical procedure called tenotomy, which involves the open division of one or more hip flexor muscles. This procedure is performed to correct deformities caused by congenital or acquired shortening of a muscle. It is important to note that CPT code 27005 specifically refers to the open approach of tenotomy for hip flexor muscles.

2. Official Description

The official description of CPT code 27005 is: ‘Tenotomy, hip flexor(s), open (separate procedure).’ This code represents the surgical division of one or more hip flexor muscles using an open approach. It is important to understand that this code is specifically for tenotomy of the hip flexor muscles and should not be used for other tenotomy procedures.

3. Procedure

1. During the tenotomy procedure, the healthcare provider begins by preparing and anesthetizing the patient appropriately.
2. An incision is made in the skin, starting from the ilium and extending along the anterior thigh.
3. The provider gains access to the hip flexor muscles, with the primary target being the iliopsoas muscle.
4. The provider carefully dissects through the subcutaneous tissue to expose the iliopsoas muscle.
5. Next, the provider separates the iliacus and psoas muscles to gain better access to the tendons.
6. The tendons are then incised or divided to lengthen them, allowing the muscle or muscles to return to their normal length.
7. In cases of severe muscle contracture, the provider may opt to completely resect the psoas muscle while preserving the iliacus muscle to maintain hip flexion.
8. Hemostasis is achieved at the surgical site, and the wound is closed by suturing the soft tissue layers.
9. A cast is typically applied to the hip for a period of three to four weeks to support healing and recovery.

4. Qualifying circumstances

CPT code 27005 is used when a patient requires the surgical division of one or more hip flexor muscles due to congenital or acquired shortening of the muscle. This procedure is typically performed to correct deformities caused by muscle contracture. It is important to note that this code specifically applies to the open approach of tenotomy for hip flexor muscles.

5. When to use CPT code 27005

CPT code 27005 should be used when a healthcare provider performs an open tenotomy procedure on one or more hip flexor muscles. This code is specific to the open approach and should not be used for other tenotomy procedures or for tenotomy of muscles in different anatomical regions. It is important to accurately document the procedure performed to ensure proper coding and billing.

6. Documentation requirements

When reporting CPT code 27005, the healthcare provider must ensure that the documentation includes the following information:

• Patient’s diagnosis necessitating the tenotomy procedure
• Details of the open approach used for the tenotomy
• Specific hip flexor muscles targeted during the procedure
• Description of the steps performed during the tenotomy
• Any additional procedures performed in conjunction with the tenotomy
• Details of wound closure and any post-operative care instructions

7. Billing guidelines

When billing for CPT code 27005, it is important to ensure that the procedure performed aligns with the specific requirements of the code. This code represents the open division of hip flexor muscles and should not be reported for other tenotomy procedures or for tenotomy of muscles in different anatomical regions. If the provider performs the 27005 procedure with an unrelated procedure, modifier 59 may need to be appended to indicate that the procedures are distinct and separate.

8. Historical information

CPT code 27005 was added to the Current Procedural Terminology system on January 1, 1990. It has undergone changes in its status as an inpatient-only (IPO) procedure, being removed from the IPO list in 2021 but added back in 2022. It is important to stay updated on any changes or revisions to ensure accurate coding and billing.

9. Examples

1. A healthcare provider performs an open tenotomy procedure on the hip flexor muscles of a patient with congenital muscle contracture.
2. A patient with acquired muscle shortening undergoes an open tenotomy procedure on their hip flexor muscles to correct a deformity.
3. A healthcare provider performs an open tenotomy procedure on the hip flexor muscles of a patient with a history of hip trauma resulting in muscle contracture.
4. An individual with a congenital hip deformity undergoes an open tenotomy procedure on their hip flexor muscles to improve joint mobility.
5. A patient with acquired muscle contracture due to a neurological condition undergoes an open tenotomy procedure on their hip flexor muscles to alleviate symptoms and improve function.
6. A healthcare provider performs an open tenotomy procedure on the hip flexor muscles of a patient with a history of repetitive strain injury.
7. An individual with a congenital muscle deformity undergoes an open tenotomy procedure on their hip flexor muscles to improve their overall quality of life.
8. A patient with acquired muscle contracture due to prolonged immobilization undergoes an open tenotomy procedure on their hip flexor muscles to restore normal muscle length.