Wiki 29848 ?

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D.R.

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West Warwick, RI
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Need another opinion please. 29848 or 64721. Provider is requesting 29848 be submitted. I feel just because the scope is inserted at the very end doesn't make it endoscopic, The approach was open. Thoughts please .......

The transverse incision at the proximal wrist crease for the carpal tunnel release was made. This was carried carefully down to the antebrachial fascia. The antebrachial fascia was incised with a U-shaped distally based flap. This was elevated off the underlying flexor tendons which were examined to ensure that we were in the appropriate compartment. A Freer elevator was used to enter the carpal tunnel and hugging the radial hook of the hamate , we ensured that we were in the appropriate position alongside direct palpation and visualization and we could see the carpal tunnel and the underlying tendons and nerve below our tunnel. A synovial elevator, small and large dilators were used to elevate the tunnel. Next the endoscope was placed and we were happy with our view, once we were satisfied with the view of the carpal tunnel, it was directly released and again inspected to ensure that this was released with the endoscope and with visualization and with palpation.
 
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D.R. said:
Need another opinion please. 29848 or 64721. Provider is requesting 29848 be submitted. I feel just because the scope is inserted at the very end doesn't make it endoscopic, The approach was open. Thoughts please .......

The transverse incision at the proximal wrist crease for the carpal tunnel release was made. This was carried carefully down to the antebrachial fascia. The antebrachial fascia was incised with a U-shaped distally based flap. This was elevated off the underlying flexor tendons which were examined to ensure that we were in the appropriate compartment. A Freer elevator was used to enter the carpal tunnel and hugging the radial hook of the hamate , we ensured that we were in the appropriate position alongside direct palpation and visualization and we could see the carpal tunnel and the underlying tendons and nerve below our tunnel. A synovial elevator, small and large dilators were used to elevate the tunnel. Next the endoscope was placed and we were happy with our view, once we were satisfied with the view of the carpal tunnel, it was directly released and again inspected to ensure that this was released with the endoscope and with visualization and with palpation.
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Well, it looks like the initial incision to place the endoscope was overly explained, and then the actual part where the endoscope was used to release the the carpal tunnel was under-explained. I would say this was endoscopic, but the doctor states "directly released" which makes it sound like it was open, so I can definitely understand the confusion. Maybe talk to the doctor directly to confirm? and if needed, ask for an addendum to the report? I hope this helps! :)
 
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