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Carpal Tunnel release?

  1. #1
    Default Carpal Tunnel release?
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    Post Op: Right Carpal Tunnel Syndrome
    Procedure: Right Carpal Tunnel Release

    Procedure: The patient was gave general anesthesia. Right upper extremity was prepped and drapped. An Esmarch wrap was applied in the proximal arm, tourniquet was inflated to 300 mmHg. Under 3.5 loupe magnification, a longitudinal curvilinear incision was made on the proximal thumb inline with the right finger. At the skin, subq tissue, palmar aponeurosis, and then the transverse carpal ligament. The ligament was divided in its entirety. Distally, the superficial arterial arch was exposed. Proximally, the ligament was divided proximal to the flexion crease of the wrist. The contents of the carpal tunnel were displayed including the median nerve and flexor tendons. The nerve was traced out to and including the motor branch. I did not feel that any separate aponeurotomy was indicated. No abnormal masses were identified. I performed a limited flexor tenosynovectomy for the second flexor tenosynovium. Adhesions were released. The wound was irrigated and tourniquet deflated. Hemostasis obtained.

    This physician has been dictating his carpal tunnel release surgeries like this and I do not feel that this supports the 64721. I have been coding the 25115, I just wanted another opinion on this. Any input is greatly appreciated. Thanks!!

  2. #2
    Typically the synovectomy would be bundled into the CTR. My thoughts are that before you started doing that, I think you should have gone to the surgeon and asked him to show you the actual release of the median nerve. Its unfortunate, but sometimes its better to educate the physicians.
    Mary, CPC, CANPC, COSC

  3. #3
    I agree with Mary!
    Stephanie Phillips, CPC-H

  4. #4
    I did query the physician and he states the carpal tunnel release was performed and the the op report is "completely clear." That is why I wanted another opinion, to see if anyone else thought this supported the carpal tunnel release. I think I was reading too much into this. Thanks!
    Last edited by bethh05; 02-10-2010 at 11:07 AM.

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