Question: What is the appropriate code(s) to report surgical treatment of carpal tunnel syndrome?
Maryland Subscriber
Answer: Coding for surgical repair of carpal tunnel syndrome (CTS, 354.0) is fairly straightforward, but depends on the approach the surgeon chooses.
For endoscopic treatment, you should apply 29848 (Endoscopy, wrist, surgical, with release of transverse carpal ligament: APC 0041).
For an open surgical repair of CTS, you should turn instead to 64721 (Neuroplasty and/or transposition; median nerve at carpal tunnel: APC 0220).
On occasion, the surgeon may also compress the ulnar nerve at Guyon’s canal (64719, Neuroplasty and/or transposition; ulnar nerve at wrist: APC 0220) to treat ulnar nerve syndrome (354.2), multiple neuritis syndrome (354.5), or injury to the ulnar nerve (955.2) during the same open session.
Note that payers will apply a multiple-procedure reduction to 64719 if you report it during the same session as 64721.
