Does CTR Include Tenosynovium Biopsy? Find out
Question: I have an operative note for an open carpal tunnel procedure where the orthopedic surgeon also performed a deep biopsy of the wrist to evaluate for the presence of amyloid protein. They stated in the documentation that they performed the biopsy “with the goal of diagnosing amyloidosis before the onset of more serious systemic manifestations.” According to the note, the surgeon excised a small amount of the tenosynovium. Can I report a biopsy code with the neuroplasty code? Ohio Subscriber Answer: No, you won’t report a biopsy code like 25066 (Biopsy, soft tissue of forearm and/or wrist; deep (subfascial or intramuscular)) with the neuroplasty code. According to the American Society for Surgery of the Hand (ASSH), “An open carpal tunnel release [CTR] includes the work of a simple biopsy of the tenosynovium.” Therefore, you’ll assign only 64721 (Neuroplasty and/or transposition; median nerve at carpal tunnel) for the procedures performed. Mike Shaughnessy, BA, CPC, Production Editor, AAPC
