Orthopedic Coding Alert

Question: A patient has a diagnosis of bilateral carpal tunnel syndrome, right worse than left. The decision is made to perform a neuroplasty on the right wrist. At the six-week postop follow-up visit, the patient also complains that the extra use of her left arm during the recovery has increased her left wrist pain significantly. The provider performs an examination of her left arm (detailed exam, history, and moderate medical decision making [MDM]) and prescribes medication, rest, and some range of motion (ROM) exercises for the patient; if symptoms do not improve within two weeks, the provider recommends that the patient schedule a follow-up visit for the left wrist pain. How should I code this scenario? Or can I code it at all, considering it occurs during the postop period of the neuroplasty?

North Carolina Subscriber

Answer: This appears to be a situation in which you should report a separate evaluation and management (E/M) service during the global period of another procedure. And in those situations, your best friend is modifier 24 (Unrelated evaluation and management service by the same physician or other qualified health care professional during a postoperative period).

Coding: For the initial surgery, you would report 64721 (Neuroplasty and/or transposition; median nerve at carpal tunnel) along with modifier RT (Right side) appended to indicate laterality, if the payer requires it.

For the unrelated E/M, you’d report 99214 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: a detailed history; a detailed examination; medical decision making of moderate complexity …) with modifier 24 appended to show that the right-sided carpal tunnel release is unrelated to the E/M for the left-sided wrist pain.