Outpatient Facility Coding Alert
Collar Carpal Tunnel Coding with the Correct Additional Character
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Look to the tabular index for your best choice.
When a patient suffers from carpal tunnel syndrome (CTS), she has a compression neuropathy. This can cause paresthesia, pain, numbness, and other symptoms in the distribution of the median nerve, possibly due to its compression at the wrist in the carpal tunnel.
The ICD-10-CM Alphabetic Index directs you to G56.0- for carpal tunnel syndrome. The dash indicates that the code needs additional characters, so you must look in the Tabular Index for complete information.
Once there, the ICD-10 system offers more clarity with separate codes for unspecified upper, right, and left limbs, as follows:
Coder tip: Under the G56 category, you’ll find an Excludes1 note that prevents you from reporting CTS with “current traumatic nerve disorder - see nerve injury by body region.”
Take Note of Related Diagnoses
Prior to the official diagnosis of CTS, you’ll need to report the patient’s care based on signs and symptoms.
Possibility 1: Previous ICD-9 code 719.4x (Pain in joint) became more specific in ICD-10 to indicate where the patient experiences pain in the wrist. The ICD-10 codes are as follows:
Possibility 2: Previous ICD-9 code 729.5 (Pain in limb) translates to M79.6x (Pain in limb, hand, foot, fingers and toes …) and explodes with a range of options based on anatomic site. The extended codes provide you with 30 options, including right, left and unspecified sites of arm (M79.601-603); forearm (M79.631-632, 639); upper arm (M79.621-622, 629); hand (M79.641-43); fingers (M79.644-646); thigh (M79.651-52, 659); leg (M79.604-605); lower leg (M79.661-662, 669); feet (M79.671-673); and toe (M79.674-76). You’ll report M79.609 for pain in an unspecified limb.
Possibility 3: Previous ICD-9 diagnosis 728.87 (Muscle weakness [generalized]) is an easy one to remember because it retains the same descriptor with M62.81.
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