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2025 CPT code 27601

Decompression fasciotomy of the leg's posterior compartment(s).

Follow current CPT coding guidelines for surgical procedures. Accurate documentation is crucial for appropriate code selection and reimbursement.

Modifiers such as LT (left side) or RT (right side) might be required depending on payer requirements.Modifier 51 might apply if multiple compartments are addressed in the same session.Modifier 76 would be appended for repeat procedure by the same physician.

Medical necessity is established based on the clinical diagnosis of compartment syndrome, characterized by elevated compartment pressures causing compromised blood flow to the muscles and nerves.Conservative measures have failed, or the severity necessitates immediate surgical decompression.

The surgeon makes an incision, exposes the fascia of the posterior compartment of the leg, and performs the fasciotomy to relieve pressure. Post-operative care and follow-up are also the responsibility of the surgeon.

IMPORTANT:27600 (anterior and/or lateral compartments only), 27602 (anterior and/or lateral, and posterior compartments)

In simple words: The doctor makes a cut to release pressure on the muscles in the back part of the leg. This helps to restore blood flow and reduce pain.

This procedure involves a surgical decompression fasciotomy, specifically targeting the posterior compartment(s) of the leg.The fascia is incised to relieve pressure and improve blood flow, addressing conditions like compartment syndrome. This may involve longitudinal and/or transverse incisions of the fascia, with excision of a small piece to allow for compartment expansion.The procedure aims to alleviate pain and prevent muscle damage.

Example 1: A patient presents with acute compartment syndrome in the posterior compartment of the leg following a high-impact tibia fracture. A fasciotomy is performed to alleviate pressure and restore blood flow to the affected muscles and nerves., A patient develops exertional compartment syndrome in their posterior leg compartment during intense athletic activity. The fasciotomy is intended to relieve the recurrent pressure symptoms experienced during strenuous exercise., A patient with chronic compartment syndrome has undergone conservative management but continues to exhibit symptoms. Surgical intervention via fasciotomy is deemed necessary to resolve the compression and improve long-term function.

Preoperative assessment including patient history, physical examination findings, and imaging studies (e.g., MRI, CT scan) documenting compartment syndrome. Intraoperative notes specifying the surgical approach, extent of fasciotomy, and any complications. Postoperative notes including wound care, pain management, and assessment of neurovascular status.Follow up appointment details.

** Accurate documentation of the compartment(s) addressed (posterior compartment only, in this case) is vital for correct coding.Consider any associated debridement or other procedures as separate codes if performed.

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