# Carpal Tunnel Surgery using the Sonex Microknife



## jfolz (Oct 25, 2017)

Has anyone had experience coding CTS done with the Sonex Microknife (including ultrasound guidance)? I code for a hospital outpatient department and have a surgeon that is going to start bringing this procedure to our location.  I am familiar with 64721, which is the code we use for the regular open CTS procedure.  
In reading what I can find online, I see some sources saying to bill it the same way with 64721 and tack on a 76942 for the ultrasound portion of the procedure and other sources calling it unlisted and saying to send it out as 64999 compared to 64721. 
 I read and reread the description of 64721 and although it reads as an open approach, I do not have an op-note yet to compare it to.  Can anyone help with discussion or how you have coded this procedure or even provide a scrubbed op note if you have one handy describing the procedure in a surgeon's words?  
I really think this is probably a percutaneous approach and therefore unlisted but I'd like to have a handle on things before they start rolling in.
Thanks!


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## fish4codes (Oct 25, 2017)

I code for hand surgeons and haven't seen this, all of ours are open; however, have you looked at 29848 (76998) ?  I look forward to others input on this!


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## jfolz (Oct 26, 2017)

fish4codes said:


> I code for hand surgeons and haven't seen this, all of ours are open; however, have you looked at 29848 (76998) ?  I look forward to others input on this!



Thanks so much for your reply!
I did come across 29848 but from what I have gathered online, it isn't really endoscopic.  There is a small knife tool that enters the wrist while an external piece performs the ultrasound portion.  So the "eyes" are outside the structure.  I do like your 76998 ultrasound code better than the 76942 that was suggested though, so thanks for that!
  I wish I just had an op note.  I will update if/when I get this figured out but I would LOVE more input if anyone else has ideas on this.
Thanks!


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## jfolz (Dec 7, 2017)

*The Op Notes are finally arriving*

"Ultrasound-guided microinvasive right carpal tunnel release and complete diagnostic ultrasound of the volar wrist and carpal tunnel"
Wrist is prepped and placed in a slight dorsiflex position.
        "The sterile ultrasound device was brought onto the field and a complete, diagnostic ultrasound was then performed starting in the short axis at the volar wrist flexion crease.  The median nerve was noted to be in the native normal location.  The flexor tendons were likewise similarly located without anomaly.  The scan in the short axis was continued proximally until the median nerve was subjacent to the flexor carpi radialis tendon.  The palmar cutaneous branch of the median nerve was then identified and noted to have its normal takeoff on the radial aspect of the median nerve towards the flexor carpi radialis tendon.  
        The probe was then moved distally in the short axis past the pisiform and to the level of the hook of the hamate.  The recurrent motor branch of the median nerve was then identified.  Its normal passage to the thenar muscles on the radial aspect of the nerve was confirmed and there were no anomalies of the motor branch to the median nerve noted.
        The long axis diagnostic maneuver was then performed from ulnar to radial.  The median nerve was noted to be in its normal position with normal fascicular architecture present.  The transverse carpal ligament was identified and a normal taper was identified distally.  The palmar arch was identified in its normal position and the midpalmar pad identified.  
       Confirming all of the anatomy in its normal condition, the procedure proceeded by placing a 25-gauge needle into the ulnar aspect of the carpal tunnel and hydrodissecting the flexor tendons away from the transverse carpal ligament in the ulnar aspect of the tunnel to create a plane for the placement of our device.  10cc of .5% Marcaine were used.
        The probe was then returned to the short axis.  A small stab wound proximally to the wrist flexion crease and just ulnar to the palmaris longus tendon was then created under ultrasound-guided positioning for ulnar entry into the carpal tunnel.  Kutz-Kleinert Elavator was then placed into the carpal tunnel, the undersurface of the transverse carpal ligament was debrided, and an excellent space was made for placement of the Sonex SX-One MicroKnife.
         The device had been prepared on the back table with priming of the balloons.  The device was placed under direct ultrasound vision with the probe in the long axis.  Distal positioning was confirmed at the taper of the transverse carpal ligament.  This was reconfirmed in the short axis as well.  The distal crossovers were checked for the ulnar artery, palmer arch, and the digital artery branches of the median nerve, all of which crossed over distal to the tip of the device. 
         At that point, the probe was returned to the short axis at the level of the hook of the hamate.  The balloons were deployed.  The probe was turned to the long axis.  The position was confirmed and the blade was deployed at this time.  The transverse carpal ligament was divided from distal to proximal under direct vision with the ultrasound in the long axis.  At the most proximal extent of the release the antebrachial fascia was released to the end of the device.  The blade was then redeployed and pushed distally back into the distal recesses position, again , all under direct visualization.
         The release appeared to be quite satisfactory.  The balloons were deflated.  The device was removed, again under direct vision of the ultrasound.  The Kutz-Kleinert was then placed into the tunnel; the release was probed and confirmed to be adequate in both the long axis and the short axis.
         The release having been competed, the procedure was concluded by closing the incision with a single horizontal mattress 4-0 nylon suture."


We are currently coding these as unlisted 64999 and 76998.  After seeing the Op Note, does anyone have any more input on the proper coding of this procedure?


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## AlanPechacek (Dec 7, 2017)

For what it is worth, a *Carpal Tunnel Release* is a Carpal Tunnel Release, *64721*, regardless of the technique (totally open, partially open, percutaneous, etc. since they all require an incision of some size or type), except for Endoscopic/Arthroscopic which has its own code, *29848*.
     The procedure as described shows both "Diagnostic" and "Therapeutic" components for the use of Ultrasound, with the Diagnostic component making certain that all the contents of the Carpal Tunnel were present and in their proper location prior to doing the actual release, which is very important.  Of course, the Therapeutic component was the Carpal Tunnel Release itself, for which Ultrasonic Guidance was also used for instrument placement and confirmation of the release being complete.  The issue then becomes which Ultrasound code to use.  *76998* is for *Intra-operative guidance* for the procedure, but wouldn't necessarily include/cover the diagnostic part.  *76999* is for *"Unlisted"* *ultrasound procedure (diagnostic, interventional)*, one or the other, but not both.  Furthermore, this code probably does not have an RVU Value, and would have to "paired" with an "equivalent" procedure code with an RVU Value, which is difficult for this procedure and I can't find a good one.  So I would probably not use this.  There is a code for *"Limited" (Diagnostic) Ultrasonic Joint or other nonvascular structures of the extremities*, *76882*, which would be great for the Carpal Tunnel Diagnostic portion of this procedure, but it requires that permanent images be taken and a separate written descriptive/interpretive report be made for the medical records.  From what I can see from the Operative Report as presented, these two elements of this code were not done.  So, this code couldn't be used (too) along with the 76998.  By process of elimination, about the only remaining useful code for the US use would be *76998*.  I might suggest that if/when your surgeon(s) do this particular procedure in the future that they do take some retained images during the Diagnostic US (and maybe at the end of the procedure), and dictate a separate "US Report" into the record, then you could use both 76998 and 76882.  They may not like it (the extra work and documentation), but they may get better compensation for their work, and I think it is medically ethical since there is no CPT code that adequately covers both the Ultrasonic Diagnostic and Therapeutic Guidance aspects of the procedure.  Be sure to submit the documentation with your claim. 

Hopefully this helps.  It will be interesting to see what others say.

Respectfully submitted, Alan Pechacek, M.D.
icd10orthocoder.com


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## jfolz (Dec 11, 2017)

AlanPechacek said:


> For what it is worth, a *Carpal Tunnel Release* is a Carpal Tunnel Release, *64721*, regardless of the technique (totally open, partially open, percutaneous, etc. since they all require an incision of some size or type), except for Endoscopic/Arthroscopic which has its own code, *29848*.
> The procedure as described shows both "Diagnostic" and "Therapeutic" components for the use of Ultrasound, with the Diagnostic component making certain that all the contents of the Carpal Tunnel were present and in their proper location prior to doing the actual release, which is very important.  Of course, the Therapeutic component was the Carpal Tunnel Release itself, for which Ultrasonic Guidance was also used for instrument placement and confirmation of the release being complete.  The issue then becomes which Ultrasound code to use.  *76998* is for *Intra-operative guidance* for the procedure, but wouldn't necessarily include/cover the diagnostic part.  *76999* is for *"Unlisted"* *ultrasound procedure (diagnostic, interventional)*, one or the other, but not both.  Furthermore, this code probably does not have an RVU Value, and would have to "paired" with an "equivalent" procedure code with an RVU Value, which is difficult for this procedure and I can't find a good one.  So I would probably not use this.  There is a code for *"Limited" (Diagnostic) Ultrasonic Joint or other nonvascular structures of the extremities*, *76882*, which would be great for the Carpal Tunnel Diagnostic portion of this procedure, but it requires that permanent images be taken and a separate written descriptive/interpretive report be made for the medical records.  From what I can see from the Operative Report as presented, these two elements of this code were not done.  So, this code couldn't be used (too) along with the 76998.  By process of elimination, about the only remaining useful code for the US use would be *76998*.  I might suggest that if/when your surgeon(s) do this particular procedure in the future that they do take some retained images during the Diagnostic US (and maybe at the end of the procedure), and dictate a separate "US Report" into the record, then you could use both 76998 and 76882.  They may not like it (the extra work and documentation), but they may get better compensation for their work, and I think it is medically ethical since there is no CPT code that adequately covers both the Ultrasonic Diagnostic and Therapeutic Guidance aspects of the procedure.  Be sure to submit the documentation with your claim.
> 
> Hopefully this helps.  It will be interesting to see what others say.
> ...



Thanks so much for your insight, Dr Pechacek.  
I read and reread 64721's description and I can agree that should cover the release portion, however large or small the incision.  (I think that I was getting hung up on the fact that the incision was the size of an arthroscopic entrance but it was not an actual arthroscopic approach.)  I also like 76998 for the intraoperative US assist and I hadn't even considered the aspect of perhaps including a code for the diagnostic portion.  Thanks so much!


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## jfolz (Mar 16, 2018)

*billing a diagnostic US with a needle placement US*

_" I might suggest that if/when your surgeon(s) do this particular procedure in the future that they do take some retained images during the Diagnostic US (and maybe at the end of the procedure), and dictate a separate "US Report" into the record, then you could use both 76998 and 76882.  They may not like it (the extra work and documentation), but they may get better compensation for their work, and I think it is medically ethical since there is no CPT code that adequately covers both the Ultrasonic Diagnostic and Therapeutic Guidance aspects of the procedure.  Be sure to submit the documentation with your claim. 

Hopefully this helps.  It will be interesting to see what others say.

Respectfully submitted, Alan Pechacek, M.D."
_
*

Dr. Pechacek (or anyone else that may know- all answers welcome!!),*
  The physician that is performing the above procedure is now dictating in the procedure line that he is doing a diagnostic ultrasound and a separate ultrasound for the needle placement. He was dictating in the body of the report thorough details but not naming it as a separate procedure when he initially started dictating for these.  This indicates to us that he is probably coding that diagnostic ultrasound for his services in addition to the needle placement US, but I code for the surgery facility and don't think I would be able to without the additional images and reporting that you mentioned above. 

*Do you know where I could find something official stating that we could bill this diagnostic US separately with the addition of that additional report and the retained images so that I could provide the physician with proof that we need those things? 
*
Thanks!


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