星空入口

Remember the ICD-10-CM 5^th character specifies laterality.

Carpal tunnel syndrome (CTS) occurs when the tunnel becomes narrowed or when the tissue surrounding the flexor tendons swells, putting pressure (compression) on the median nerve and reducing its blood supply.

Last month, Revenue Cycle Insider broke down the CTS condition and examined the diagnostic testing procedures. In the second part of this series, you鈥檒l learn about the nonsurgical and surgical treatment options, as well as the ICD-10-CM codes you鈥檒l need to complete your CTS-related claims.

Don鈥檛 forget to check out part 1 from last month鈥檚 Revenue Cycle Insider before reading part 2.

Examine the Suggested Treatments for CTS

The surgeon may suggest nonsurgical treatments to address early symptoms, such as:

• Wearing a wrist splint or brace
• Nonsteroidal anti-inflammatory drugs (NSAIDs)
• Activity changes (e.g., modified work duties)
• Nerve gliding exercises
• Steroid injections

Scenario: An orthopedist sees a patient for a follow-up appointment to address the patient鈥檚 bilateral CTS. The patient states the pain is persisting even after wearing wrist splints and taking NSAIDs as necessary. The orthopedist injects each wrist with 5 mg of triamcinolone acetonide.

For this scenario, you鈥檒l assign 20526 (Injection, therapeutic (eg, local anesthetic, corticosteroid), carpal tunnel) appended with modifier 50 (Bilateral procedure) to indicate the provider performed the injection on both of the patient鈥檚 wrists. Next, you鈥檒l report G56.03 (Carpal tunnel syndrome, bilateral upper limbs) to show the medical necessity for the procedure.

Lastly, report J3301 (Injection, triamcinolone acetonide, not otherwise specified, 10mg) for the corticosteroid.

Note: Check payer policy for modifier preference; some payers may prefer billing the code on two lines and append RT (Right side) and LT (Left side).

When surgical treatment is recommended, medical documentation should include the response to non-operative treatments, physical exam findings, severity of symptoms, and results of testing. If sufficient pain relief is not achieved by these measures and significant nerve damage is noted on testing, carpal tunnel release will be performed.

Examine Open Vs. Endoscopic Carpal Tunnel Release

Surgeons perform carpal tunnel release using one of two different surgical techniques, but the goal of both is to decompress the median nerve. This is done by cutting the ligament that forms the roof of the tunnel (transverse carpal ligament). The release of this ligament increases the size of the tunnel and alleviates pressure on the median nerve, allowing for appropriate blood flow and restoring proper function of the nerve.

There are key differences between open and endoscopic carpal tunnel release surgeries. Knowing the differences will help you identify the procedure while examining the operative note:

• Incision size: Open surgery has a larger incision (around 2 inches) while endoscopic uses a smaller incision, also known as portal access (half an inch)

• Visual access: Open surgery provides direct visual access to the surgical site, while the endoscopic approach uses a camera for visualization

• Recovery time: Typically, a patient experiences quicker recovery with less pain and earlier return to activity following an endoscopic approach

• Scarring: Due to the smaller incision, the endoscopic approach usually results in less noticeable scarring

Open carpal tunnel release surgery: You鈥檒l assign 64721 (Neuroplasty and/or transposition; median nerve at carpal tunnel) to report open carpal tunnel release. Neuroplasty is a surgical procedure that decompresses or frees the nerve from scar tissue. The procedure may include external neurolysis or transposition to repair or restore the nerve.

The CPT^庐 code book includes a parenthetical note under the 64716-64721 range instructing you not to report any of the codes with 11960 (Insertion of tissue expander(s) for other than breast, including subsequent expansion).

When the orthopedic surgeon performs internal neurolysis during the carpal tunnel release, you鈥檒l assign +64727 (Internal neurolysis, requiring use of operating microscope (List separately in addition to code for neuroplasty) (Neuroplasty includes external neurolysis)).

Since +64727 is an add-on code, you cannot report the code separately without also billing 64721 or another applicable primary procedure code. You should also not assign 64721 if an operating microscope was not used and documented during the procedure.

Additionally, you can鈥檛 assume that all payers will have the same billing guidelines; always check with each payer.

Endoscopic carpal tunnel release surgery: Assign 29848 (Endoscopy, wrist, surgical, with release of transverse carpal ligament) when the documentation indicates the surgeon performed an endoscopic surgery for carpal tunnel release. This code also features a parenthetical note instructing you not to report 29848 with 11960.

Modifiers: Both 64721 and 29848 are unilateral codes. Check the payer鈥檚 policy for its preference on reporting bilateral procedures. Either append modifier 50 to the single code or bill the code on two lines and append modifiers RT and LT.

Expert tip: Do not report code 64721 with code 29848 for the same wrist at the same encounter.

Why? When an endoscopic release of the transverse carpal ligament is converted to an open release, report only the open procedure code.

Don鈥檛 Forget the Diagnosis Codes

The CTS diagnosis codes can be found in Chapter 6: Diseases of the Nervous System in the ICD-10-CM code book. Each code requires five characters, which specify the laterality. The CTS codes are:

• G56.00 (Carpal tunnel syndrome, unspecified upper limb)
• G56.01 (Carpal tunnel syndrome, right upper limb)
• G56.02 (Carpal tunnel syndrome, left upper limb)
• G56.03 (Carpal tunnel syndrome, bilateral upper limb).

Misty Smith, CPC, COSC, 星空入口Subject Matter Expert