2025 CPT code 29894
(Active) Effective Date: N/A Revision Date: N/A Surgery - Surgical Procedures on the Musculoskeletal System Feed
Arthroscopy of the ankle (tibiotalar and fibulotalar joints) with removal of loose or foreign body.
Modifiers may be applicable. For example, Modifier 51 would be appended if this procedure is performed with another procedure during the same surgical session.Modifier 76 should be used by same physician performing the repeat procedure, while 77 should be used by different physician performing the repeat procedure.
Medical necessity for this procedure must be established by documenting the patient's symptoms, physical examination findings, imaging results, and failed conservative treatments. The documentation should support that the loose/foreign body is the cause of the patient's symptoms and that arthroscopic removal is the most appropriate treatment.
The physician is responsible for preparing the patient, performing the arthroscopic procedure, removing the loose or foreign body, managing any complications, and providing post-operative care.
In simple words: The doctor uses a small camera and tools inserted through tiny cuts in your ankle to look inside your ankle joint and remove any loose bits of bone, cartilage, or other material that shouldn't be there. This procedure is done to relieve pain and improve joint movement.
This code describes a surgical procedure where an arthroscope is used to visualize and remove a loose or foreign body from the tibiotalar and fibulotalar joints of the ankle.The procedure involves making small incisions, inserting the arthroscope and instruments, and removing the loose or foreign body. It is important to note that per CPT guidelines, this code may only be reported when the loose/foreign body is equal to or larger than the diameter of the arthroscopic cannula used and can only be removed through a larger cannula, separate incision, or enlarged portal.
Example 1: A patient experiences ankle pain and limited range of motion after twisting their ankle. Imaging reveals a loose body in the tibiotalar joint. Code 29894 is used for the arthroscopic removal of the loose body., A patient has persistent ankle pain following a previous ankle fracture.A small bone fragment is identified as a foreign body within the fibulotalar joint. Code 29894 is reported when the fragment is removed arthroscopically., A patient presents with ankle swelling and discomfort after a sports injury. An arthroscopy reveals a piece of cartilage that has broken off and is now a loose body in the ankle joint. This loose body is equal to or larger than the diameter of the arthroscopic cannulas and needs to be removed. CPT code 29894 would be appropriate.
Documentation should include details of the procedure, size and type of loose/foreign body removed, instruments used, any complications encountered, and confirmation that the loose/foreign body met the size criteria as defined in CPT guidelines.
- Specialties:Orthopedic Surgery, Podiatric Surgery
- Place of Service:Ambulatory Surgical Center, Hospital Outpatient Department, Office