How To Use CPT Code 27696

CPT 27696 describes the primary repair of disrupted ligaments in the ankle joint. This article will cover the description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples.

1. What is CPT Code 27696?

CPT 27696 is used to describe the primary repair of both the medial and lateral collateral ligaments in the ankle joint. This procedure is performed when these ligaments have been disrupted due to an acute injury, such as a dislocation or sprain. The purpose of the procedure is to restore function and relieve pain in the ankle joint.

2. Official Description

The official description of CPT code 27696 is: ‘Repair, primary, disrupted ligament, ankle; both collateral ligaments.’

3. Procedure

1. The provider begins by making an incision over the lateral or medial malleolus, being careful not to damage the sural nerve.
2. Next, the provider identifies and exposes the remnant of the lateral or medial collateral ligament by dissecting the anterior tissues.
3. The transverse ligament is then incised, and a periosteal flap is folded over the anterior fibula, overlapping the edges.
4. The provider proceeds to debride the distal tip of the fibula using a curette and surgical blade.
5. Decortication of the bone is performed using a burr to provide a bleeding bony bed for healing and suture anchor placement.
6. A drill hole is made in the fibula, and the remnant of the lateral collateral ligament is sutured and anchored in the holes in the distal fibula.
7. Finally, the wound is closed.

4. Qualifying circumstances

CPT 27696 is performed on patients who have experienced a disruption of both the medial and lateral collateral ligaments in the ankle joint. This may occur as a result of an acute injury, such as a dislocation or sprain. The procedure is intended to restore function and alleviate pain in the ankle joint.

5. When to use CPT code 27696

CPT code 27696 should be used when the provider performs the primary repair of both the medial and lateral collateral ligaments in the ankle joint. It is important to note that this code is specific to cases where both ligaments are repaired. If only one ligament is repaired, a different code should be used.

6. Documentation requirements

To support a claim for CPT 27696, the provider must document the following information:

• The diagnosis indicating the disruption of both medial and lateral collateral ligaments
• A detailed description of the procedure performed, including the specific steps taken
• The date of the procedure
• The start and end time of the procedure
• Any additional relevant information, such as the use of suture anchors or other specific techniques
• The provider’s signature

7. Billing guidelines

When billing for CPT 27696, it is important to ensure that the procedure meets the criteria for primary repair of both collateral ligaments in the ankle joint. Modifier 62, Two surgeons, should be appended if the provider is acting as a cosurgeon with another provider. It is also important to review the Medicare Physician Fee Schedule and other payer guidelines to determine if documentation is required to support the use of a cosurgeon modifier.

8. Historical information

CPT 27696 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 patient sustains an ankle injury resulting in the disruption of both the medial and lateral collateral ligaments. The provider performs a primary repair of these ligaments to restore stability and alleviate pain in the ankle joint.
2. Following a severe sprain, a patient’s ankle ligaments are disrupted. The provider performs a primary repair of both the medial and lateral collateral ligaments to restore function and relieve pain.
3. An individual dislocates their ankle, causing damage to the medial and lateral collateral ligaments. The provider performs a primary repair of these ligaments to restore stability and improve the patient’s mobility.
4. After a sports-related injury, a patient experiences a disruption of both the medial and lateral collateral ligaments in their ankle. The provider performs a primary repair of these ligaments to restore function and alleviate pain.
5. A patient presents with a dislocated ankle and disrupted medial and lateral collateral ligaments. The provider performs a primary repair of these ligaments to restore stability and improve the patient’s overall ankle function.
6. Following a traumatic injury, a patient’s ankle ligaments are disrupted. The provider performs a primary repair of both the medial and lateral collateral ligaments to restore stability and alleviate pain.
7. An individual sustains a severe sprain, resulting in the disruption of both the medial and lateral collateral ligaments in their ankle. The provider performs a primary repair of these ligaments to restore function and relieve pain.
8. After a car accident, a patient’s ankle ligaments are disrupted. The provider performs a primary repair of both the medial and lateral collateral ligaments to restore stability and improve the patient’s mobility.
9. A patient injures their ankle during a sports activity, causing damage to the medial and lateral collateral ligaments. The provider performs a primary repair of these ligaments to restore function and alleviate pain.
10. Following a fall, a patient presents with a dislocated ankle and disrupted medial and lateral collateral ligaments. The provider performs a primary repair of these ligaments to restore stability and improve the patient’s overall ankle function.