Orthopedic Coding Alert

Question: After an initial consult, our orthopedic surgeon documented suspected carpal tunnel syndrome (CTS). May I report CTS, or should I report the patient's signs and symptoms?

Missouri Subscriber

Answer: You should report the patient's signs and symptoms because the surgeon has not yet determined and documented a definitive diagnosis.

Result: Instead of reporting 354.0 (Carpal tunnel syndrome), you should report the patient's documented signs and symptoms, such as the following:

- pain in the hand, wrist and/or forearm (729.5, Pain in limb)

- numbness and tingling (782.0, Disturbance of skin sensation)

- muscle weakness (728.87, Muscle weakness [generalized]).

Reason: ICD-9 official guidelines instruct you to use signs and symptoms codes in the office setting when the documented diagnosis is uncertain, stating: "Do not code diagnoses documented as -probable,- -suspected,- -questionable,- -rule out,- or -working diagnosis- or other similar terms indicating uncertainty. Rather, code the condition(s) to the highest degree of certainty for that encounter/visit, such as symptoms, signs, abnormal test results, or other reason for the visit" (Section IV. I, page 90). You can find the guidelines online at http://www.cdc.gov/nchs/datawh/ftpserv/ftpicd9/icdguide07.pdf.