Bilateral Carpal Tunnel Procedures – Different Days

Question:

We are going to be doing bilateral carpal tunnel procedures on a patient – the right side will be done first then the left will be done 8 weeks later. Should I use modifier 58 (staged procedure) on the 2nd procedure?

Answer:

Actually, it’s best to use modifier 79 (unrelated procedure in a global period) because the left side (2nd procedure) is unrelated to the right side (1st procedure). Be sure to use the laterality specific ICD-10-CM codes – G56.01 (Carpal tunnel syndrome, right upper limb) and G56.02 (Carpal tunnel syndrome, left upper limb) – for the respective procedures.