How To Use CPT Code 27625

CPT 27625 describes a specific procedure performed on the ankle joint. 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 27625?

CPT 27625 is a code used to describe a surgical procedure involving the ankle joint. It involves making an incision over the ankle area, dissecting down through the subcutaneous tissue to the joint capsule, and performing an arthrotomy with synovectomy. This procedure is performed to diagnose and treat problems of the ankle joint.

2. Official Description

The official description of CPT code 27625 is: ‘Arthrotomy, with synovectomy, ankle.’

3. Procedure

1. The provider prepares the patient and administers anesthesia.
2. An incision is made over the ankle area.
3. The provider dissects through the subcutaneous tissue to reach the joint capsule.
4. The joint capsule is incised and opened.
5. The provider explores the joint space and identifies the diseased synovium.
6. The diseased synovium is removed through a synovectomy.
7. The wound is irrigated with antibiotic solution.
8. The joint capsule is closed.
9. The soft tissue is closed in layers using sutures, staples, or sterile adhesive strips.

4. Qualifying circumstances

CPT 27625 is performed on patients who have ankle joint problems that require an arthrotomy with synovectomy. This procedure is typically performed by a surgeon. The patient must meet the necessary criteria for anesthesia and surgical intervention.

5. When to use CPT code 27625

CPT code 27625 should be used when a provider performs an arthrotomy with synovectomy on the ankle joint. It is important to ensure that the procedure performed matches the description provided by the code. If the procedure performed does not align with the code description, a different code should be used.

6. Documentation requirements

To support a claim for CPT 27625, the provider must document the following information:

• Patient’s diagnosis and the need for the arthrotomy with synovectomy
• Description of the procedure performed, including details of the incision, dissection, synovectomy, and closure
• Date of the procedure
• Any complications or additional procedures performed
• Signature of the provider

7. Billing guidelines

When billing for CPT 27625, ensure that the procedure performed matches the code description. It is important to follow the specific guidelines provided by the payer for accurate billing. Modifier 62 may be appended if the procedure was performed by two surgeons. It is important to check with the payer for any specific requirements or restrictions related to billing CPT 27625.

8. Historical information

CPT 27625 was added to the Current Procedural Terminology system on January 1, 1990. There have been no updates or changes to the code since its addition.

9. Examples

1. A surgeon performs an arthrotomy with synovectomy on a patient with ankle joint inflammation.
2. An orthopedic specialist performs an arthrotomy with synovectomy to remove a loose body from the ankle joint.
3. A patient with chronic ankle pain undergoes an arthrotomy with synovectomy to alleviate symptoms.
4. A podiatrist performs an arthrotomy with synovectomy on a patient with ankle joint arthritis.
5. A patient with ankle joint infection undergoes an arthrotomy with synovectomy for drainage and treatment.
6. An orthopedic surgeon performs an arthrotomy with synovectomy on a patient with ankle joint instability.
7. A patient with ankle joint trauma undergoes an arthrotomy with synovectomy for repair and rehabilitation.
8. A surgeon performs an arthrotomy with synovectomy on a patient with ankle joint impingement.
9. An athlete with ankle joint ligament damage undergoes an arthrotomy with synovectomy for repair and rehabilitation.
10. A patient with ankle joint tumor undergoes an arthrotomy with synovectomy for tumor removal.