B Posted Wed 24th of August, 2016 13:39:08 PM
I need to know how to properly code this procedure and the diagnosis given in the op report:
Right elbow cubital tunnel syndrome.
1 . Right elbow cubital tunnel release .
2 . Anterior subcutaneous transposition of the ulnar nerve .
3 . Epineurolysis ulnar nerve I Lys)s of adhesions
ANESTHESIA: Laryngeal mask airway.
DESCRIPTION OF PROCEDURE: The patient was brought into the
operating suite and placed supine on the operating table. Then,
600 mg of IV clindamycin was given for preoperative antibiotics
as the patient. has allergy to penicillin . Her right a rm was
placed on an arm board . A tourniquet was applied to the
p r oximal arm and preset to 250 mmHg of pressure . The patient
was then placed under adequate laryngeal mask airway anes thesia.
An Esmarch bandage was utilized to exsanguinate the l i mb and
tourniquet was inflated . Time out was performed, the pat ient' s
identity and procedure and right side was confirmed and the
procedure was commenced. An incision was made from 5- cm distal
to the medial epicondyle to several centimeters proximal on the
right elbow . The incision was carried through the subcutaneous
tissue wit h littler scissors and spreading technique.
Electrocautery was utilized as needed . The cubL:al tunnel was
then entered bluntly with a mosquito clamp over which the 15-
blade was utili zed to transect the aponeurosis . Cubital tunnel
release was performed e xposing the ulnar nerve . Vessel loops
were placed around the ulnar nerve for manipulation . Dissection
was carr ied p r oximally to the intermuscular s eptum . Digital
palpation revealed no obstructions proximally . Dissection was
then carried distally to the flexor retinaculum and aponeurosis1
and the ulnar nerve was freed and transposed anteriorly.
Attention was given for proper orientation of the nerve and
aqequate placements. Next, util izing 4- 0 Vicryl , subcutaneous
transposition was performed by suturing the subcutaneous tissue
of the flap posterior to the nerve to prevent the nerve
subluxating posteriorly .
An adequate nerve bed was created and the nerve was placed in
the subcutaneous tissue without undue tension . The proximal and
di stal extents of the nerve were noted to be free of kinking or
undue tension. The cubital tunnel was then reapproximated with
4- 0 simple and mattress- type sutures. At this point, tourniquet
was released at 25 minutes and hemostasis was achieved. The
wound was thoroughly irrigated. The subcutaneous tissue was
closed wi t h 4- 0 Vicryl sutures and the skin was '::losed with 3- 0
nylon horizontal mattress sutures. Xeroform was applied.
Sterile dre s s ings were applied and the arm was wrapped with Ace
wrap wi thout t ension . An arm sling was applied. The patient
was then ~wakened , the LMA removed, and she was placed on a
transport bed and taken to recovery room in stabl e condition .
Blood loss was minimal. The patient tolerated the procedure
we ll . Sponge, needle and instrument counts were correct at the
end of the case . Total tourniquet time was 25 minutes .
SuperCoder Answered Thu 25th of August, 2016 01:04:04 AM
B Posted Tue 30th of August, 2016 19:55:37 PM
ok can I get the correct codes for
Diagnosis- Right elbow cubital tunnel syndrome
Right elbow cubital tunnel release
Anterior subcutaneous transposition of the ulnar nerve
Epineurolysis ulnar nerve
B Posted Tue 30th of August, 2016 19:58:17 PM
ok can I get the correct codes for Diagnosis- Right elbow cubital tunnel syndrome CPT- Right elbow cubital tunnel release, Anterior subcutaneous transposition of the ulnar nerve and Epineurolysis ulnar nerve
SuperCoder Answered Wed 31st of August, 2016 01:05:29 AM
Diagnosis code for Right elbow cubital tunnel syndrome is G56.21.
B Posted Wed 31st of August, 2016 08:17:17 AM
thank you. How about the procedure code for
Right elbow cubital tunnel release, Anterior subcutaneous transposition of the ulnar nerve and Epineurolysis ulnar nerv
B Posted Wed 31st of August, 2016 11:05:49 AM
Basically the doctor did a Right elbow cubital tunnel release, an anterior subcutaneous transposition of the ulnar never, an Epineurolysis of the ulnar nerve ad a Lysis of adhesion.
I believe CPT 64718 cover the cubital tunnel release, the anterior subcutaneous transposition of the ulnar never, and the Epineurolysis of the ulnar nerve. However, I cannot find anywhere how to code the Lysis of adhesion for that particular area? Also, I only bill cpt 64718 once, correct?
SuperCoder Answered Thu 01st of September, 2016 01:23:41 AM
64718-RT seems the correct code choice. There is no particular code for reporting lysis of adhesion for that particular area. I could not see removal of adhesion in the documentation provided by you in detailed operative report. You will report code once.