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Is unbundling justified when done through the same incision with separate dx's? I advised the surgeon only CTR was billable, but she wants to add a 59 due to separate diagnoses (ganglion and CTS.)
Next, a 2cm longitudinal incision was made beginning 0.5 cm distal to the transverse wrist crease in line with the ulnar border of palmaris longus and heading towards the radial border of the ring finger. Proximally this incision was extended in a radial direction over the prominence of the cyst. Dissection was carried down through subcutaneous tissue and cautery was used to ensure hemostasis. The palmar fascia was identified and divided distally, revealing the underlying transverse carpal ligament. The transverse carpal ligament was sharply incised along it's length, distally to the level of palmar fat and proximally to the level of the antebrachial fascia with care being taken to preserve the underlying structures. Once a complete release was ensured with visual inspection and Freer palpation, the wound was copiously irrigated.
Attention was then turned to the cyst. The cyst was noted to be a large, multiloculated and arising from 2 separate stalks, 1 which appeared to be coming from the volar aspect of the STT joint and the second from the radiocarpal region. These were carefully dissected free from surrounding tissue. The underlying fascia was incised and the radial artery and accompanying veins were carefully protected. The cysts were excised in their entirety. The stalks were excised from the origin of the joint and a portion of capsule was excised along with it. Any further cystic appearing tissue was removed
Next, a 2cm longitudinal incision was made beginning 0.5 cm distal to the transverse wrist crease in line with the ulnar border of palmaris longus and heading towards the radial border of the ring finger. Proximally this incision was extended in a radial direction over the prominence of the cyst. Dissection was carried down through subcutaneous tissue and cautery was used to ensure hemostasis. The palmar fascia was identified and divided distally, revealing the underlying transverse carpal ligament. The transverse carpal ligament was sharply incised along it's length, distally to the level of palmar fat and proximally to the level of the antebrachial fascia with care being taken to preserve the underlying structures. Once a complete release was ensured with visual inspection and Freer palpation, the wound was copiously irrigated.
Attention was then turned to the cyst. The cyst was noted to be a large, multiloculated and arising from 2 separate stalks, 1 which appeared to be coming from the volar aspect of the STT joint and the second from the radiocarpal region. These were carefully dissected free from surrounding tissue. The underlying fascia was incised and the radial artery and accompanying veins were carefully protected. The cysts were excised in their entirety. The stalks were excised from the origin of the joint and a portion of capsule was excised along with it. Any further cystic appearing tissue was removed