Wiki Status Post Carpal Tunnel

[LLRodgers]

If a patient has Carpal Tunnel Release 3/18/15 and comes in for a follow up on 5/4/15

Diagnosis: Status post carpal tunnel release with some mild soft tissue swelling and ulnar bursitis starting to cause some early triggering of ring finger.

The soft tissue swelling could be from the surgery. However, the ulnar bursitis and the triggering I am not sure of.

Would I code the ulnar bursits and triggering with an E/M code and then code a V45.89 - status post with a 99024?

Any suggestions would be greatly appreciated.

Thank you,
Linda

 

[talitha82]

I would query your provider, clarify if the ulnar bursitis is a separate issue- perhaps have him/her add an addendum stating that it is unrelated to surgery. Than you can code a separate E/M level, with a modifier 24 along with your 99024 for post op visit. Make sure you follow the CPT guidelines for separately reportable E/Ms and ensure you have appropriate documentation. You might also have to add a modifier 25 to that, but I am a bit rusty on whether you would need to do both a 25, 24 or just 24.

 

[dustie]

I agree. I would check with the provider just to clarify bursitis is not related.
If it is not related, this is how myself and my provider would code it.

726.4
E/M 9921_
V45.89
99024

I hope this helps
Dustie CPC