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Tenolysis and Ganglion excision

Taylor Posted Thu 09th of April, 2015 16:55:21 PM

How do I code for excision of volar wrist ganglion and release of flexor carpi radialis tendon? Is the ganglion excision inclusive to the tendon release. Here is an excerpt from the operative report:

I made a Bruner incision over the volar radial aspect of the wrist. I identified the ganglion and had significant fascial tissue over it. I dissected out the fascial tissue. I dissected out the radial artery and had my assistant protect it during the entire procedure. I then identified the volar wrist ganglion. I identified the stalk which went into the FCR tendon sheath. I excised the ganglion and then I released the flexor carpi radialis tendon completely so that there would be no areas of impingement.

SuperCoder Answered Fri 10th of April, 2015 02:48:13 AM

CPT codes for excision of ganglion, wrist are 25111 (primary) and 25112 (recurrent). CPT code for release of flexor carpi radialis tendon is 25295. As per NCCI edits, CPT 25295 is included in CPT code 25111 and 25112. You can report 59 modifier to make it distinct procedure, but your operative report is not supporting -59 modifier here. Please use the appropriate CPT code for excision of wrist ganglion only.

Taylor Posted Fri 10th of April, 2015 12:15:49 PM

Are you able to advise on what the operative report would need to include to support the 59 modifier?

SuperCoder Answered Mon 13th of April, 2015 00:46:19 AM

To support the -59 modifier, it should be on different anatomical location or through different incision.

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