How To Use CPT Code 27057

CPT 27057 describes a procedure known as decompression fasciotomy, specifically in the pelvic (buttock) compartment. This article will cover the description, official details, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples.

1. What is CPT Code 27057?

CPT 27057 is used to report the decompression fasciotomy procedure performed in the pelvic (buttock) compartment. This procedure involves making an incision into the fascia surrounding the affected muscle compartment in the hip to relieve pressure and improve blood flow. It is typically performed on one side of the buttock.

2. Official Description

The official description of CPT code 27057 is: ‘Decompression fasciotomy(ies), pelvic (buttock) compartment(s) (eg, gluteus medius-minimus, gluteus maximus, iliopsoas, and/or tensor fascia lata muscle) with debridement of nonviable muscle, unilateral.’ This code can be used to report the procedure when performed on one side of the buttock. If the procedure is performed bilaterally, modifier 50 should be appended to the code.

3. Procedure

1. The provider begins by making an incision in the skin overlying the affected area in the pelvic compartment.
2. They then access the fascia above the affected muscle compartment.
3. The provider incises the fascia and removes any damaged or nonviable muscle and/or nerve tissue.
4. This decompression fasciotomy reduces pressure on the neurovascular structures beneath the fascia, restoring blood supply and relieving symptoms.
5. If necessary, the incision may be left open for drainage, or the provider may close the wound by suturing the soft tissues in layers.

4. Qualifying circumstances

CPT 27057 is used when the provider performs a decompression fasciotomy in the pelvic (buttock) compartment. This procedure is typically performed to relieve pressure caused by compartment syndrome, a condition characterized by increased pressure in a muscle compartment, leading to muscle and nerve damage and reduced blood flow. The procedure may involve the gluteus medius-minimus, gluteus maximus, iliopsoas, and/or tensor fascia lata muscles. It is important to note that CPT 27057 is reported for a unilateral procedure. If the procedure is performed bilaterally, modifier 50 should be appended to the code.

5. When to use CPT code 27057

CPT code 27057 should be used when the provider performs a decompression fasciotomy in the pelvic (buttock) compartment on one side. It is important to ensure that the procedure is performed in the specified compartment and that it involves the appropriate muscles. If the procedure is performed bilaterally, modifier 50 should be appended to the code.

6. Documentation requirements

To support a claim for CPT 27057, the provider must document the following information:

• Patient’s diagnosis and the need for decompression fasciotomy
• Specific muscles involved in the procedure
• Date of the procedure
• Details of the procedure, including the incision, fasciotomy, and debridement
• Any additional procedures performed during the same session
• Signature of the provider

7. Billing guidelines

When reporting CPT 27057, ensure that the procedure is performed in the pelvic (buttock) compartment and involves the specified muscles. If the procedure is performed bilaterally, modifier 50 should be appended to the code. It is important to follow the specific guidelines provided by the payer and accurately document the procedure to support the claim.

8. Historical information

CPT code 27057 was added to the Current Procedural Terminology system on January 1, 2009. There have been no updates to the code since its addition.

9. Examples

1. A provider performs a decompression fasciotomy in the pelvic (buttock) compartment to relieve pressure caused by compartment syndrome in a patient’s gluteus medius muscle.
2. During a procedure, the provider performs a decompression fasciotomy in the pelvic (buttock) compartment, specifically targeting the gluteus maximus muscle.
3. A patient undergoes a decompression fasciotomy in the pelvic (buttock) compartment to alleviate pressure on the iliopsoas muscle.
4. A provider performs a decompression fasciotomy in the pelvic (buttock) compartment, focusing on the tensor fascia lata muscle to relieve pressure and restore blood flow.
5. During a procedure, the provider performs a decompression fasciotomy in the pelvic (buttock) compartment, targeting multiple muscles, including the gluteus medius-minimus and tensor fascia lata.