CPT code 64721 is used to report carpal tunnel release surgery. Here are some coding tips for using this code:
- Confirm medical necessity: Before assigning a CPT code for carpal tunnel release, it is important to confirm that the procedure was medically necessary. This may involve reviewing the patient’s medical history, diagnostic imaging, and any other relevant clinical information.
- Correctly assign the code: Make sure that the procedure is accurately described by CPT code 64721. This code specifically refers to an open carpal tunnel release, meaning that the surgeon made an incision in the patient’s wrist to access the carpal tunnel.
- Know the surgical approach: There are different approaches to carpal tunnel release, including open, endoscopic, and mini-open techniques. It is important to know which approach was used to select the appropriate CPT code.
- Use the appropriate modifiers: Depending on the specifics of the surgery, additional modifiers may be necessary to indicate changes to the procedure or to provide additional information. For example, modifier -50 may be used to indicate a bilateral procedure, while modifier -RT and -LT may be used to indicate right and left sides, respectively.
- Ensure complete documentation: Accurate and complete documentation is crucial when coding for carpal tunnel release. The documentation should include information about the surgical approach, any intraoperative findings or complications, and the patient’s post-operative status.
- Follow local guidelines: Be sure to follow any local coding guidelines or payer policies that may impact coding for carpal tunnel release. Some payers may have specific requirements for documentation or coding of certain procedures.