Skip to content

Coding Tip of the Month – July 2017

Fasciotomy for Compartment Syndrome


Postoperative diagnosis: status post polytrauma left lower extremity status post motorcycle accident with elevated compartment pressure for the lateral as well as the medial compartments.

Procedure: The compartment pressures of the patient’s four compartments were measured. For the anterior and lateral compartments the measurement was 32, for the posterior compartment superficial and deep, it was 34. With this information, we proceeded with fasciotomy medially decompressing the superficial as well as the deep posterior compartments. Muscle in these compartments was contractile. Anterolateral incision was then made and carried down through the fascia anterolaterally with opening of the fascia on the anterior as well as the lateral compartment. What PCS code(s) are assigned for this procedure?


0KNT0ZZ Release left lower leg muscle, open approach

0KNT0ZZ Release left lower leg muscle, open approach

0KNT0ZZ Release left lower leg muscle, open approach

0KNT0ZZ Release left lower leg muscle, open approach


In this case, the fasciotomy meets the root operation definition of “Release;” freeing a body part from an abnormal physical constraint by cutting or by using force. The ICD-10-PCS code can be assigned multiple times for each compartment released (i.e., two compartment fasciotomy, four compartment fasciotomy, etc.). The ICD-10-PCS Official Guidelines for Coding and Reporting, Multiple Procedures, Section B3.2b, state, “During the same operative episode, multiple procedures are coded if: The same root operation is repeated in multiple body parts, and those body parts are separate and distinct body parts classified to a single ICD-10-PCS body part value.”

Clinical Information:

Groups of organs or muscles are organized into areas called compartments. Strong webs of connective tissue called fascia form the walls of these compartments. Compartment syndrome occurs when excessive pressure builds up inside an enclosed muscle space in the body. The tough walls of fascia cannot easily expand, and compartment pressure rises, preventing adequate blood flow to tissues inside the compartment. Compartment syndrome usually results from bleeding or swelling after an injury. The dangerously high pressure in compartment syndrome impedes the flow of blood to and from the affected tissues. Fasciotomy or fasciectomy is a surgical procedure where the fascia is cut to relieve tension or pressure commonly to treat the resulting loss of circulation to an area of tissue or muscle.

Anatomy of Compartments:

Upper Arm – 2 compartments

Forearm – 4 compartments

Hand – 4 compartments

Thigh – 3 compartments

Lower Leg – 4 compartments

Foot – 9 compartments