Ask Dr. Z

Please advise as to what CPT codes would be appropriate. Does the response in question ID 15139 apply to this case?

The patient's identity, planned procedure, and laterality were confirmed. The skin overlying the lateral right hip was prepped and draped in usual sterile fashion. The skin and subcutaneous tissues were anesthetized with 1% lidocaine solution. Under ultrasound guidance, a 20-gauge spinal needle was advanced near the greater trochanter and the deeper soft tissues were anesthetized using 0.25% bupivacaine solution. Subsequently, percutaneous needling (tenotomy) was performed by gently fenestrating the distal gluteus medius and minimus tendons using the 20-gauge spinal needle. Once the fibrosis/scar tissue was released and the tendons were adequately softened, the needle was removed.

IMPRESSION:

1. Right gluteus medius and minimus insertional tendinopathy.

2. Uncomplicated ultrasound-guided percutaneous needle tenotomy of the right gluteus minimus and medius tendon insertions.