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CPT 25115 RT and 64721 59RT

  1. Default CPT 25115 RT and 64721 59RT
    Medical Coding Books
    For any of my subject matter experts with regards to the above coding scenario- opinions regarding coding would be greatly appreciated and welcomed:


    Preoperative DX: Recurrent carpal tunnel syndrome, right wrist
    Post Op DX: Recurrent carpal tunnel syndrome, right wrist
    Procedures Performed: Decompression and neurolysis, right median nerve at the wrist


    The Op Report indicates the following:

    "The median nerve was found to be compressed and erythematous. Extensive neurolysis and synovectomy were carried out as needed"

    Would CPT 25115 RT and 64721 RT be appropriate for the above scenario?

    I am aware that these codes are bundled when billed in conjunction with one another- therefore my gut is telling me that modifier 59 appended to CPT 64721 is most likely not appropriate. Any direction would be appreciated.

    Thanks in advance!

  2. #2
    Default
    Need an op note to answer your question.
    Kelly A Mcfadyen, CPC

  3. Default
    Quote Originally Posted by KMCFADYEN View Post
    Need an op note to answer your question.
    Thanks for the reply and sorry for the delay in response. Below is the op report notes:

    Operative Report

    Preoperative DX: Recurrent carpal tunnel syndrome, right wrist
    Post Op DX: Recurrent carpal tunnel syndrome, right wrist
    Procedures Performed: Decompression and neurolysis, right median nerve at the wrist

    Operative Findings:

    Patient has been having pain, tingling and numbness in her right hand. it has been progressive and not responsive to splinting and non-operative treatment. Surgical decompression was discussed and the patient agreed.

    Description of Procedure:

    Patient brought to the operating room and given sedation. A tourniquet was placed about the arm. Then, 10cc of 1% plain Xylocaine was used to anesthetize the right palm and wrist along the volar aspect. The arm was then prepped and draped in a sterile fashion. The arm was exsanguinated and the tourniquet was inflated. A curvilinear incision was made in the palm of approximately 3 to 4 cm. First knife was used for the skin. The deep tissue was sharp and bluntly dissected with dissecting scissors. Electrocautery was used for hemostasis as needed. Second knife was used to open the carpal tunnel. This was carried out proximally and distally with a scalpel. Scissors were used to augment this. The median nerve was found to be compressed and erythematous. Neurolysis and synovectomy were carried out as needed. There was no specimen. There was no significant blood loss. The wound was closed with 6-0 nylon suture. A sterile dressing was applied. A sling was applied. Circulation was intact. The patient was transferred to the recovery room in satisfactory condition.


    CPT 25115 RT and 64721 59RT were billed- my feeling is that only 64721 should have been billed.
    Last edited by lurleen78; 10-02-2014 at 01:41 PM.

  4. #4
    Default
    I agree only 64721 should have been billed. if the synovectomy had been performed thru a separate incision then I probably would have coded the 25115 with the 59 modifier. seeing as how the carpal tunnel is recurrent and he did perform synovectomy as well i probably would have added a 22 modifier to the procedure.

  5. Default
    Quote Originally Posted by michellelgrd View Post
    I agree only 64721 should have been billed. if the synovectomy had been performed thru a separate incision then I probably would have coded the 25115 with the 59 modifier. seeing as how the carpal tunnel is recurrent and he did perform synovectomy as well i probably would have added a 22 modifier to the procedure.
    Thank you! Glad to see I was on the right path!

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