25020 is inclusive to 64721. However, the 25020 is being paid because that is the higher RVU CPT and 64721 is secondary to it. If you look at the NCCI edits, you will see. The reason is standards of medical surgical practice. If you look up in the NCCI info you can see what that means. The "longer incision" in this case does not matter. I would also question reporting 25020 for this report above. Usually the patient has compartment syndrome when you see the CPT. Did this provider's op notes suddenly change in content/wording for all carpal tunnel surgery which would normally have been 64721? If you compared the "older" op notes for 64721 to when he started wanting to report this different way, do they read differently?
Division of the transverse carpal ligament, with or without Z-plasty or other local tissue rearrangement is included in 64721. Extension of the incision to include transverse carpal ligament is included in 25020.
Are any of the appeals being won? I bet no. 59 is being appended inappropriately in this case.
If you have a copy of the AAOS Complete Global Surgery Data books it's in there.
Also show the NCCI P2P edits and manual.
https://www.cms.gov/files/document/medicare-ncci-policy-manual-2024-chapter-1.pdf
B. Coding Based on Standards of Medical/Surgical Practice
"Services integral to HCPCS/CPT code defined procedures are included in those procedures based upon the standards of medical/surgical practice.
It is inappropriate to separately report services that are integral to another procedure with that procedure.
"He states that other providers in his specialty are billing this successfully and getting paid"
Beware of that statement above. Did he recently attend a conference, was he having a chat with colleagues? Are the "other providers" in the same state, billing the same payer (WC may pay for both), does the payer the "other" is billing follow NCCI, are they being paid for unbundling incorrectly? Are the "other" providers getting takebacks, recoups and audits? Can he give you any credible documented publication or reputable source such as CMS, payer, CPT Assistant, AAOS, Coding Clinic, AMA other than "talk amongst surgeons" to support coding this way?
Another approach is to show the numbers, how many were billed in say, a 90 day or 6 month period, how many were denied? How many were paid? How many appeals were won? What is the denial reason? Showing the $ and numbers helps sometimes.
Follow the same process to look up 64718 P2P edits and global surgery book info. Although 64718 is at the elbow. That seems a bit different to me depending on the diagnosis and op report you are looking at.
This can all be payer dependent also keep in mind if they don't follow NCCI/CMS.
