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wmcodylee

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Can someone help me to make sure I've coded the following op report correctly?

Post op diagnosis: Right carpal tunnel syndrome
Right volar wrist mass

Operations Performed: Right Carpal decompression
Excision of right volar wrist mass
Flexor Tenosynovectomy
Neurolysis, external of the median nerve

Description of procedure:
A 15-blade was used to make an axial incision directly ove the carpal tunnel in the mid palm directly between the hypothenar and thenar eminences. The incision was approximately 1.5 cm long. This was carried down to subcutaneous tissue. retractor was placed within the confines of the would to afford exposure. dissection continued down until the palmaris longus was encountered. This was incised longitudinally and the palmaris brevis musculature was spread until the transverse carpal ligament was exposed. This was incised for a short distance. Care was taken to preserve the median nerve underneath.

Next the sled for the carpal tunnel knife was advanced proximally into the wrist underneath the transverse carpal ligament with care being taken to keep the median nerve under the sled. After this was done, the knife was advanced in the groove in the sled dividing the proximal portion of the transverse carpal ligament. Next, the knife and sled were removed and advanced distally towards the head of the fourth metacarpal underneath the transverse carpal ligament.

After sled was advanced, the knife was then advanced in the groove in the sled, dividing the transverse carpal ligament distally. The sled and knife were withdrawn. The wound was inspected and the transverse carpal ligament was noted to be divided completely along its length. The median nerve was intact.

A 15-blade was used to make a transverse incision directly over the area of the mass. The skin flap was elevated. The mass was turned out to be inflamed tenosynovium just proximal to the edge of the transverse carpal ligament. It was excised completely using tenotomy scissors. Flexor tenosynovectomy was performed and was passed off as field specimen. It should be noted that neurolysis of the median nerve was performed at the same time as this mass was somewhat adherent to the nerve.

My codes:
D48.1 - 26145-RT, 25075-51 RT, 64722-51 RT
G56.01 - 64721, 59 RT

Any help would be appreciated!!! Thank you!!!
 
Hi wmcodylee: I'm a relatively new coder for a group of hand surgeons and find these questions particularly interesting and useful for me. Reading your case, your carpal tunnel is correct (64721-RT); however, the second procedure, the mass removal, opens up questions. First of all, what did the path report say it was - if it was inflammed synovium that would be the dx code (see M65.9) and the procedure would be 26145-RT. (Your neurolysis is the 64721 assuming it was external, not internal, so you can't use that again and I don't see where a "tumor" was excised, only the synovectomy.) I would code this 64721-RT and 26145, 51-RT (there are no NCCI edits). Hopefully, someone will confirm or correct what I think! Good luck...
 
After reviewing the Op Report as presented, it appears your physician tried to do some "unbundling" in that his "procedures" include "Right Carpal decompression" and "Neurolysis, external of the median nerve" which are essentially the same thing, i.e. Neuroplasty (Exploration, Neurolysis or Nerve Decompression) of the Median Nerve at the wrist, 64721 (Carpal Tunnel Release). He did this for G56.01, Right Carpal Tunnel Syndrome. These are Diagnosis and Procedure Code for number 1.

Next, Dx and Procedure #2, he did an "Excision of right volar wrist mass" which turned out to be the "Flexor Tenosynovectomy," (which will have to be confirmed by the Pathology Report for the correct postoperative/final diagnosis). In other words, his Volar Wrist Mass was a collection/lump of Tenosynovitis of the Flexor Tendons at the distal forearm and wrist. Therefore, the D48.1 code would not be necessary or correct, and the code should be for the Flexor Tenosynovitis of the Forearm and Wrist, but not in the hand or fingers. The "best" code I can find for this is M65.831: Other synovitis and tenosynovitis of the Forearm and (right) Wrist. An alternative possibility would be M67.231: Synovial Hypertrophy, NEC, in the Forearm and (right) Wrist, which is what chronic tenosynovitis can do over time, i.e. become a "mass" of tissue/synovium. Last, but not least, and adding to the confusion for diagnosis coding, is M67.831: Other specified disorder of synovium (and/or tendon) at the the right wrist. Of all of these, I would go with M65.831 as it "seems" to be the most specific. As for the procedure done for this, 25115 is the correct code as it is for Flexor Tenosynovectomy in the Forearm and Wrist. The code suggested above, 26145, is for Tenosynovectomy of the Flexor Tendons of the Hand/palm &/or Fingers. His report indicates that his incision for, and the location of the "mass," was proximal to the Transverse Carpal Ligament, i.e. not in the Hand.

In so far as he used two separate incisions, then the Modifier 51 is probably better than any of the Modifier 59 variations for the Tenosynovectomy.

Hopefully this helps.

Respectfully submitted, Alan Pechacek, M.D.
icd10orthocoder.com
 
Thank you once again Dr. Pechacek - I was hoping you would chime in on this one. As always, you expertise is appreciated and very much appreciated!
 
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