Wiki Tenolysis of flexor carpi radialis

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such78

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DX:
1. left volar ganglion cyst
2. Flexor tendinitis

Procedure performed: Tenolysis of flexor carpi radialis

A zigzag incision over the radiocarpal joint was carried out and extended to the base of the thrumb and the reinaculum of the wrist was incised to expose the flexor carpi radialis and its course, and there was no evidence of a ganglion cyst, but there was evidence of a tremendous amount of synovitis. Thus tenolysis was then performed by performing a synovectomy. upon completion of this and examination of operative area, there was no evidence of cyst.


Should I query the surgeon to specify the complete description of the procedure (synovectomy and tenolysis)?

Thanks for advice.
 
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The first diagnosis should not be documented. Per the surgeon there was no ganglion cyst, so it cannot be listed as a diagnosis.

Per the surgeon's documentation synovectomy was performed which is removing inflamed synovial tissue.

Tenolysis is debriding either an inflamed tendon, or separating the tendon from adhesions that have formed. This is not the same thing as synovectomy.

As it stands you can't bill anything because nothing matches up. You can't bill a synovitis procedure with a diagnosis of ganglion cyst and flexor tendonitis, they don't match.
 
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Orthocoderpgu said:
The first diagnosis should not be documented. Per the surgeon there was no ganglion cyst, so it cannot be listed as a diagnosis.

Per the surgeon's documentation synovectomy was performed which is removing inflamed synovial tissue.

Tenolysis is debriding either an inflamed tendon, or separating the tendon from adhesions that have formed. This is not the same thing as synovectomy.

As it stands you can't bill anything because nothing matches up. You can't bill a synovitis procedure with a diagnosis of ganglion cyst and flexor tendonitis, they don't match.
Click to expand...

Thanks for your valuable advice. I am going to create a query.
 
0
Orthocoderpgu said:
The first diagnosis should not be documented. Per the surgeon there was no ganglion cyst, so it cannot be listed as a diagnosis.

Per the surgeon's documentation synovectomy was performed which is removing inflamed synovial tissue.

Tenolysis is debriding either an inflamed tendon, or separating the tendon from adhesions that have formed. This is not the same thing as synovectomy.

As it stands you can't bill anything because nothing matches up. You can't bill a synovitis procedure with a diagnosis of ganglion cyst and flexor tendonitis, they don't match.
Click to expand...


Surgeon reposed the query" by tenolysis of the flexor carpi radials, the description of the procedure will be such that the flexor tendon sheath was a strip of his synovium that was impinging within the soft tissue around the capsule of the radiocarpal joint, so the radiocarpal joint area was also opened to free up a localized area in order to safeguard against recurrence of tenosynovitis."

It seem like the surgeon only performed the tenolysis.

Am I correct to assign 26440 ?
 
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I would only bill 26440. Opening the radiocarpal joint was a preventative measure taken that is directly related to the tenosynovitis and its in the same anatomical location. It would be included.
 
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