Wiki Carpal Tunnel Sx & Distal Fasciotomy

I have a provider who is insistent on billing CPT 64721 with CPT 25020. I have tried to explain on multiple occasions that it is not appropriate to bill these together. We have received multiple denials, unfortunately though, we have also received payments on both, so I am having a hard time making him understand why we cannot continue to bill this when even Medicare is paying them. From my understanding, through my research, the distal fasciotomy is a much more extensive procedure and is not just the additional cut during the CTS Sx that his documentation states. In my opinion the biggest issue with this is when we do get paid, it is on the Distal Fasciotomy and not the Carpal Tunnel Sx. I also understand from his nurse that this entire procedure, Carpal Tunnel & Distal Fasciotomy combined is about <= 1 inch incision.

Any help in how to better explain this or any documentation examples that anyone has on a Distal Fasciotomy would be so great. Also, if anyone is billing these together, are you getting any positive results with your appeals? I have gone as far as reaching out to other ortho offices in the area to find out if anyone else is billing this way and have been told by 3 others "NO", they used to, but haven't been billing together for years.

The following is an example of the documentation provided:

PREOPERATIVE DIAGNOSIS: Carpal tunnel syndrome, left wrist
POSTOPERATIVE DIAGNOSIS: Carpal tunnel syndrome, left wrist.

PROCEDURE:
l. Open carpal tunnel release, left wrist.
2. Distal forearm fasciotomy, left wrist.

ANESTHESIA: General via laryngeal mask airway with local infiltration per surgeon.
COMPLICATIONS: None.

DESCRIPTION OF PROCEDURE: The patient was taken to the operative suite by Anesthesia after a general anesthetic was achieved via an LMA. Local infiltration was placed at the end of the operative procedure for a median nerve block and local infiltration in the palm. The skin was then marked with a marking pen in the ring finger access proximal palm. The arm was exsanguinated with an Esmarch and tourniquet was inflated. The skin was then incised in the ring finger axis of the proximal palm. It was carried through the skin and subcutaneous tissues. Small bleeders were coagulated with bipolar electrocautery. The palmar fascia was incised parallel to the incision to reveal the transverse carpal ligament. The patient had a significant amount of vascular tissue directly at the distal end. Care was taken to protect this area under loupe magnification and the transverse carpal ligament was opened up to the antebrachial fascia.

At this point a plane was developed both superficial and deep to this confluence. Using a pair of Metzenbaum scissors a distal forearm fasciotomy was completed to decompress the medial nerve throughout this entire region, from the distal forearm into the carpal canal and distally. All fibers had been released under direct vision using loupe magnification. The area was irrigated with saline to remove any loose or foreign debris. The skin edges were allowed to fall back together and reapproximated with 5-0 Prolene. The tourniquet was deflated. Circulation returned to the hand and the fingers immediately. A dressing contained Xeroform gauze, 4 x 4s, sponge, cast padding, and an Ace wrap for light compression. The patient tolerated the procedure well without any complication and was transferred to recovery in stable condition.

Thank you all for your time and review of this information.

25020 is used for compartment syndrome.
Read the includes/excludes of 64721. If the intent it carpal tunnel release/decompression (decompress median nerve as stated above) it is 64721.

Do you have a copy of the AAOS Global Service Data books? It shows 64721 includes 25020. Further, you would have to append a 59 modifier on 64721 which is not supported by this documentation.
The NCCI edit is "standards of medical surgical practice"
B. Coding Based on Standards of Medical/Surgical Practice
"Many NCCI PTP edits are based upon the standards of medical/surgical practice. Services that are integral to another service are component parts of the more comprehensive service. When integral component services have their own HCPCS/CPT codes, NCCI PTP edits place the comprehensive service in Column One and the component service in Column Two. Since a component service integral to a comprehensive service is not separately reportable, the Column Two code is not separately reportable with the Column One code.

The only reason the 25020 would be paid if billed together with 64721 without a 59 is because it has a higher RVU.

You can also refer to the AMA clinical vignettes for the CPTs.

Also, just because a claim is paid does not mean it was coded correctly. That is a very bad thing to base what someone thinks is correct coding off of.
Based on that note, it is 64721.

Amy beat me to it.

The distal antebrachial fascia is confluent woth the transverse carpal ligament and part of the standard release of the median nerve.

GSD clearly includes this within 64721.

It is not separately reimbursable except when you are doing full forearm fasciotomies for compartment syndrome.

Trying to unbundle this is entirely inappropriate, and the fact that you might have gotten paid for it in the past would not be a viable legal excuse in the event of an audit, nor would it prevent clawbacks.

Feel free to tell the surgeon to ask the Coding committees of either AAOS, ASSH or ASPN and he will 100% get the exact same response. His professional organizations are entirely of one mind on this.

Same as when you asked this question before

amyjph said:

Also, just because a claim is paid does not mean it was coded correctly. That is a very bad thing to base what someone thinks is correct coding off of.
Based on that note, it is 64721.

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Thank you! I 100% Agree with you, it is just convincing the provider of that. We have spoken to him about all the information and resources you mentioned. We are just going to have to show it all to him in writing. Thank you again, I just wanted to verify that I had everything we needed to state our case for refusing to bill the services.

NRaizman said:

Feel free to tell the surgeon to ask the Coding committees of either AAOS, ASSH or ASPN and he will 100% get the exact same response. His professional organizations are entirely of one mind on this.

Click to expand...

Thank you for that resource as well. I have never had a provider fight me so hard on correctly coding services and trying to avoid an audit.

In addition to everything previously mentioned, have you spoke to your provider about not having a diagnosis for 25020? As Dr. Raizman has pointed out 25020 is performed to treat compartment syndrome, which the patient does not have.

mkdred07 said:

Thank you for that resource as well. I have never had a provider fight me so hard on correctly coding services and trying to avoid an audit.

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I feel for you, I have had some of the same struggles in the past. One of mine was why we wouldn't/couldn't report intra-op fluoro on every single case... or unbundle codes with separate procedure designation that were clearly inclusive to the primary.

Are you representing a billing service or work for the practice? Is there an internal compliance reporting program (which there should be)? Is there a compliance committee or c-level individual it could be brought up to? If it were me and I was getting nowhere, and I was an individual contributor role such as a coder, I would go up the chain. If these are being billed this was to Medicare, Medicaid or anywhere else but especially to government payers and being paid, you need to escalate it. It is putting the practice and provider at risk whether they see that or not. I assume this is a hand and wrist surgeon and the CPT frequency on these is probably high. You'll also have to go back and pull all of these CPT and refund if they were paid inappropriately. Really needs to go to the coding manager, CFO, RCM manager, etc.

Amy makes good points. I come at it from a slightly different perspective. I am the coding compliance officer for a 170-surgeon orthopaedic group, but was also chair of coding committees for ASSH and ASPN, sit on the coding committee for AAOS, and represent ASSH to the RUC. As a surgeon, I can speak to surgeons directly and likely get a little less flak than you guys, who are often seen by surgeons as part of an administrative oversight and burden that they don't like, as part of a controlling bureaucracy or health system that doesn't care about them, as non-surgeons who don't understand the work that they are doing, or as fighting against their reimbursement, all of which create a power struggle and lead to confrontation, which is not fun for any of us.

I basically put it to them like this - your coders are there to protect you. From audits, from clawbacks, from legal liability, from bad press, and from, eventually, jail and restitution. The surgeon is legally responsible for his or her coding, even if he or she is unaware of the rules and subtleties, and pleas of ignorance have -never- gotten surgeons out of legal hot water. If your coder is telling you something is bundled, you're welcome to challenge that, and they should give you justification, and you're welcome to seek answers from your specialty societies (at ASSH and AAOS and ASPN, any member can query our coding committees. For AAOS you need to be a Code-X subscriber but otherwise it is both free and simple), but your coders are there to CYA. I tell them "you can perseverate with this, but if your coders don't support you and your professional societies don't support you, you are way out on a limb, and the fact that you've gotten paid in the past, just means there's more money to claw back if a payor decides it was inappropriate and you get audited. Every organization has strict legal requirements for reporting any questionable coding violations or fraud, a limited time frame to do so, and they will do so at the expense of any single surgeon, so don't put yourself at risk. No practice or institution or health system has that much allegience to their surgeons that they won't cut them loose to look better amid allegations of fraud, so don't put yourself out on a limb for a few bucks. It's just not worth it."

That argument usually works. They think of this stuff in terms of justice amid declining reimbursements and a system that increasingly doesn't care about health care practitioners. They need to realize they're just throwing themselves under the bus.

But still, if this surgeon persists, send him to ASSH or AAOS so he can see just how far out on a limb he is.