Wiki Excision of mass left small finger, left carpal tunnel release


Rothbury, MI
Best answers
How would you code this? I am reading mucoid degeneration and he keeps extending the incision, but I don't think an actual cyst was removed. The carpal tunnel was not planned, can I bill it with the cyst excision 26160 or should I bill the arthrotomy with exploration 26070-26080?

Preoperative diagnosis: Left small finger mass
Postoperative diagnosis: Same
Operation performed: Excision of mass left small finger, left carpal tunnel release
Anesthesia: Block converted to general

Indications: Extreme pain left small fingertip

Procedure: Patient was taken to the operating on 9/15/20. She was first given a Bier block. Next her forearm, arm, and hand were prepped and draped in normal sterile fashion. Next an incision was made over the volar aspect of the tip of her left small finger. Immediately upon making this incision mucoid material came pouring out of the wound. I then extended the incision in a Bruner zigzag fashion to the PIP flexion crease to try and ascertain where the cyst was coming from. There was diffuse mucoid degeneration in the skin and subcutaneous tissue in the flexor sheath as well. In order to trace the origin of this mucoid material I extended the incision even more further proximally using a 15 blade. As I progressed and on the carpal tunnel mucoid material came pouring up the sheath out into the wound so it was apparent that there was a more proximal origin of this degenerative mucoid material. I extended the incision into the palm and even into the carpal tunnel with a 15 blade. I completely released the transverse carpal ligament. Upon releasing the transverse carpal ligament I looked at the nerve. There also appeared to be a nerve tumor which I removed taking care to injure the nerve as little as possible. This did not appear to be the origin of the mucoid material but was noted upon the dissection. To the best that I could tell the mucoid degenerative tissue appeared to be coming from the radiocarpal joint or possibly the midcarpal joint. I could not say for certain once I had expressed all the mucoid material that I could I cauterized the area on the volar aspect of the floor of the carpal tunnel where I believed the mucoid material may have been originating from and irrigated the wound with copious amounts of saline. I then closed the incision with running 5 and on modified horizontal mattress suture and released the tourniquet.

Complications: None
Estimated blood loss: Minimal
Specimen: Multiple specimens were taken
Tourniquet time: 1 hour 3 minutes
Operative time:
Was the tumor sent to pathology? Frequently my doc will say that he removed a cyst just to find out that it was a tumor and vise versa. If there is a path report I would find that out since it will change the code that submitted. The carpal tunnel release is incidental which you seem to realize. Your not asking if it should be billed. You may want to query your doc as well. The cyst material seems to be coming from the joint capsule, but the capsule was not entered at least according to the documentation. If so have an addendum done. I would bill 26160-22, find out about the capsule and the tumor since one of those could be billed as well.