Orthopedic Coding Alert

Question: In a patient who was diagnosed with chronic right lateral epicondylitis and radial tunnel syndrome along with posterolateral elbow impingement symptoms, our surgeon did the following procedures:

1.   Right radial tunnel decompression with posterior interosseous nerve neurolysis.

2.   Lateral epicondyle release with partial lateral epicondyle ostectomy and denervation of the epicondyle with excision of the posterior cutaneous nerve along the lateral ridge.

3.   Posterior arthrotomy with triceps split and decompression impinging tissue, posterolateral joint.

Alaska Subscriber

Answer: For the right radial tunnel decompression with posterior interosseous nerve neurolysis, you report code 64708 (Neuroplasty, major peripheral nerve, arm or leg, open; other than specified). You report

24358 (Tenotomy, elbow, lateral or medial [e.g., epicondylitis, tennis elbow, golfer’s elbow]; debridement, soft tissue and/or bone, open) for the partial lateral epicondyle ostectomy and denervation of the epicondyle. For arthrotomy, the best choice is 24102 (Arthrotomy, elbow; with synovectomy).

Additionally, you report the following diagnosis codes:

·         726.32 (Lateral epicondylitis) for the chronic right lateral epicondylitis

·         354.3 (Lesion of radial nerve) for the radial tunnel syndrome

·         719.43 (Pain in joint involving forearm) for the elbow pain due to posterolateral impingement.