How To Use CPT Code 64786

CPT 64786 describes the excision of a neuroma on the sciatic nerve. This article will cover the description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples.

1. What is CPT Code 64786?

CPT 64786 is used to describe the excision of a neuroma on the sciatic nerve. This procedure is performed to relieve pain and restore nerve function that has been lost due to a neuroma caused by injury or trauma.

2. Official Description

The official description of CPT code 64786 is: ‘Excision of neuroma; sciatic nerve.’

3. Procedure

1. The provider prepares the patient and administers anesthesia.
2. An incision is made on the back of the thigh or buttocks to access the sciatic nerve.
3. The provider locates the neuroma and carefully separates it from the surrounding tissue.
4. The neuroma is then excised, or removed, from the sciatic nerve.
5. The provider closes the tissue and skin using sutures or other appropriate methods.

4. Qualifying circumstances

CPT 64786 is performed on patients who have a neuroma on the sciatic nerve that is causing pain and loss of nerve function. The procedure is typically done in cases where the neuroma is a result of injury or trauma. It is important to note that this code specifically applies to the excision of a neuroma on the sciatic nerve and not on other major peripheral nerves.

5. When to use CPT code 64786

CPT code 64786 should be used when a provider performs the excision of a neuroma on the sciatic nerve. It is important to ensure that the procedure is specifically targeting the sciatic nerve and not another major peripheral nerve. If the excision is performed on a different major peripheral nerve, a different CPT code should be used.

6. Documentation requirements

To support a claim for CPT code 64786, the provider must document the following information:

• Patient’s diagnosis of a neuroma on the sciatic nerve
• Details of the procedure, including the incision site and the steps taken to locate and excise the neuroma
• Any complications or additional procedures performed during the surgery
• Post-operative care instructions and follow-up plans
• Signature of the provider performing the procedure

7. Billing guidelines

When billing for CPT code 64786, ensure that the procedure performed is specifically the excision of a neuroma on the sciatic nerve. It is important to accurately document the details of the procedure and any additional services provided. There are no specific guidelines regarding reporting CPT code 64786 with other codes, but it is important to ensure that the codes accurately reflect the services performed.

8. Historical information

CPT code 64786 was added to the Current Procedural Terminology system on January 1, 1990. There have been no updates or changes to the code since its addition.

9. Examples

1. A patient presents with severe pain and loss of function in their leg due to a neuroma on the sciatic nerve. The provider performs an excision of the neuroma, relieving the patient’s symptoms and restoring nerve function.
2. After a thorough examination, a provider diagnoses a patient with a sciatic nerve neuroma. The patient undergoes surgery to have the neuroma excised, resulting in pain relief and improved nerve function.
3. A patient who has been experiencing chronic pain in their buttocks and leg is found to have a neuroma on the sciatic nerve. The provider performs an excision of the neuroma, providing the patient with relief from their symptoms.
4. Following a traumatic injury, a patient develops a neuroma on their sciatic nerve. The provider performs surgery to remove the neuroma, allowing the patient to regain normal nerve function and alleviate their pain.
5. A patient with a history of sciatic nerve injury presents with persistent pain and limited mobility. The provider identifies a neuroma on the sciatic nerve and performs an excision, resulting in improved function and reduced pain for the patient.