Left ulnar nerve entrapment at the elbow
What is the correct CPT code with modifier for the following scenario
REOPERATIVE DIAGNOSIS: Left ulnar nerve entrapment at the elbow
POSTOPERATIVE DIAGNOSIS: Left ulnar nerve entrapment at the elbow
PROCEDURE: Left ulnar nerve decompression at the elbow
INDICATIONS: The patient has a history of numbness in the fourth and fifth digits of the left hand and
also some weakness in the grip. He complains of pain in the ulnar side of the left arm. He had an
EMG, which was positive for entrapment of the left ulnar nerve at the elbow, and he had conservation
treatment with some improvement of the mode of function, with severe significant numbness and pain.
Because of the symptoms, the decision was made to proceed with a decompression of the left ulnar
nerve at the elbow.
DESCRIPTION OF SURGERY: The patient was placed in supine position with the left hand on the surgical
stand. The arm was then prepped, draped, and then an incision was marked at the level of the left
elbow. The incision was infiltrated with lidocaine 1 percent and then the incision was made with a
#15 blade. With the use of bipolar coagulator, the bleeding was easily controlled and then the ulnar
nerve was exposed at the level of the elbow proximally and distally. The ulnar nerve was completely
compressed and was released from a dense scar. Antibiotic solution was used to irrigate the area, and
then the area was closed with #3-0 Vicryl and staples.
What is the appropriate CPT code?
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