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Neurology & Pain Management Coding Alert

You Be the Coder :

Feel Your Way Through CTS Diagnosis

Published on Sat Jan 02, 2010

Question: My neurologist has a patient who presented with tingling and pain in her right hand. He performed both motor and sensory nerve conduction studies and an EMG test. He documented possible carpal tunnel syndrome (CTS) as the final electrodiagnostic test findings and ordered a diagnostic ultrasound study to verify CTS. Should I just code for CTS as the diagnosis now to save time? Texas Subscriber Answer: No, you cannot report 354.0 (Carpal tunnel syndrome) in this case because your neurologist did not confirm CTS. You should only report signs and symptoms if your physician does not confirm CTS, or if the patient has additional symptoms that are not associated with CTS. If the documentation supports it -- and to establish medical necessity for the diagnostic studies your neurologist has performed -- you would code the applicable signs and symptoms of CTS: numbness and tingling (782.0) aching pain in the thumb, index, [...]
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