Open incision into the ankle joint for exploration, drainage of fluid, or removal of a foreign body or loose material.

Verified May 8, 2026 · 6 sources ↓

Medicare: $609.57
Total RVUs: 18.25
Global, days: 90
Region: Foot & ankle

Drawn from CMSAcgmeAAOSFastrvu

Documentation requirements

What must appear in the operative or office note to support the claim.

Source · Editorial brief grounded in 6 cited references ↓

Operative note must state the specific indication (infection, hematoma, foreign body, effusion) requiring open arthrotomy rather than arthroscopic approach.
Document the approach by name (anteromedial, anterolateral, posterior) — notes that say 'standard ankle arthrotomy' invite audit flags.
Record the findings at exploration: volume and character of fluid drained, presence and description of any foreign body or loose material removed, synovial appearance.
If billing same-day with fracture fixation, document that the arthrotomy was a separately indicated, distinct service from the fracture repair — timing and rationale must be explicit.
Pre-operative diagnosis and post-operative diagnosis should be recorded separately; a change between the two supports medical necessity when the procedure was exploratory.
For modifier 22, document quantified additional work: dense adhesions, aberrant anatomy, or prolonged operative time with specific minutes noted.

Applicable modifiers

Modifiers commonly billed with this code.

Source · AMA CPT modifier descriptors · CMS NCCI Policy Manual

22 Increased complexity 24 Unrelated E/M during global 25 Significant separate E/M 51 Multiple procedures 57 Decision for surgery 58 Staged or related 59 Distinct service 76 Repeat, same physician 78 Unplanned return — related 79 Unrelated during global 80 Assistant surgeon AS PA/NP/CNS assistant LT Left side RT Right side XS Separate structure

What this code covers

Source · Editorial summary grounded in 6 cited references ↓

27610 covers an open arthrotomy of the ankle — the surgeon incises the joint capsule, then explores the joint space to address pathology such as accumulated fluid, infection, hematoma, or a retained foreign body. The procedure is diagnostic and therapeutic in a single setting when the clinical picture demands direct visualization rather than arthroscopic access.

The 90-day global period means all routine post-op care through day 90 is bundled. If you're also billing fracture fixation (e.g., 27814 for bimalleolar ORIF) on the same day, expect NCCI bundling scrutiny — hematoma evacuation at the fracture site does not automatically justify separate billing of 27610 without clear documentation that the arthrotomy was a distinct, separately indicated service. Modifier 59 or XS requires specific documentation support, not just a surgeon preference.

Distinguish 27610 from 27620, which adds joint exploration with or without biopsy and removal of loose bodies as specifically defined components. Use 27625 or 27626 when synovectomy is the primary intent. Site-of-service matters here: HOPD and ASC payment rates differ substantially — see the Site of Service comparison table on this page.

RVU & reimbursement

Component RVUs and Medicare national rate. Actual payment varies by GPCI locality.

Source · CMS Physician Fee Schedule, RVU26A · January 2026

Work RVU	8.9
Practice expense RVU	7.71
Malpractice RVU	1.64
Total RVU	18.25
Medicare national rate	$609.57
Global period	90 days

Payment by site of service

Medicare pays different rates by setting. HOPD typically pays substantially more than ASC for the same procedure.

Source · CMS OPPS Addendum B·ASC HCPCS payment rates·2026

Setting	Medicare rate (national)
Office (PFS non-facility) Procedure performed in physician's office	$609.57
HOPD (APC 5113) Hospital outpatient department	$3,342.87
ASC (PI A2) Ambulatory surgical center (freestanding)	$1,644.87

Common denial reasons

The recurring reasons claims for CPT 27610 get rejected.

Source · Editorial brief grounded in CMS NCCI edits, AAOS coding appeals, and cited references ↓

Bundling with same-day fracture fixation (e.g., 27814) when hematoma evacuation is not documented as a distinct, separately indicated procedure.
Lack of medical necessity documentation when arthroscopic access was available and no contraindication to arthroscopy is recorded.
Missing laterality modifier (LT or RT) causing claim rejection or payer-specific edit failures.
Operative note that describes only generic 'exploration' without recording intraoperative findings, failing to substantiate a separately payable service.
Global period conflicts when post-op E/M visits are billed without modifier 24 and payer determines they are routine follow-up bundled into the 90-day global.

Frequently asked questions

Source · Generated from the editorial pipeline, verified against 6 cited references ↓

01Can 27610 and 27814 be billed together on the same day?

It's possible but scrutinized. NCCI bundles open joint procedures with fracture fixation at the same anatomic site. To separate them, you need documentation that the arthrotomy was a distinct, separately indicated service — not simply hematoma evacuation incidental to the ORIF. Modifier 59 or XS with explicit operative note support is required; payer policy varies on whether the edit is bypassable.

02What is the global period for 27610?

90 days. All routine post-operative visits, dressing changes, and stitch removals through day 90 are bundled. E/M services for unrelated conditions in that window need modifier 24; a significant, separately identifiable E/M on the day of surgery needs modifier 25.

03How does 27610 differ from 27620?

27610 is the simpler arthrotomy — incision, exploration, drainage, or foreign body removal. 27620 adds joint exploration with or without biopsy and removal of loose or foreign bodies as specifically defined components. When biopsy or loose body removal is the primary intent and the procedure is more involved, 27620 is the appropriate code.

04Is modifier 50 appropriate if both ankles are treated in the same operative session?

Yes. Modifier 50 applies when the identical procedure is performed bilaterally in the same session. Bill a single line with modifier 50. Some payers prefer two lines with LT and RT instead — verify payer-specific billing instructions before submitting.

05When is modifier 78 used versus modifier 79 for a return to the OR after 27610?

Modifier 78 is for an unplanned return to the OR for a procedure related to 27610 — for example, re-exploration for persistent infection within the 90-day global. Modifier 79 is for an unrelated procedure during the global period. Do not invert these: using 79 when the return is clearly related to the original ankle procedure is a compliance risk.

06Does site of service affect reimbursement for 27610?

Yes, substantially. HOPD and ASC payment rates differ — see the Site of Service comparison table on this page. The physician's professional fee is also subject to the site-of-service differential under the CMS Physician Fee Schedule 2026, with a lower practice expense RVU when the procedure is performed in a facility setting.

Sources & references

Editorial content was developed using the following public sources. Last verified May 8, 2026.

Mira AI Scribe

Mira's AI scribe captures the surgical indication, approach name, intraoperative findings (fluid character and volume, foreign body description, synovial status), and any distinct rationale for open versus arthroscopic access — all directly from dictation. That documentation prevents the two most common denials for 27610: bundling challenges when fracture fixation is billed same-day, and medical necessity rejections when the operative note doesn't explain why open arthrotomy was required.

See how Mira captures CPT 27610 documentation