Wiki ICD10 QUESTION

[DEBRA WEAVER]

1st question If a patient comes in and is diagnosed with for example pain knee, has an mri, then comes back and there is a definite strain of the muscle s86.811_. Is this new diagnosis code appended with the 7th character as an "A" since it was the first time the code was used (even though the patient has been treating for this), or should it have the 7th character as an "D" for subsequent.

2nd question If a patient comes in with the complaint of bilateral carpal tunnel g56.03, and it is mentioned, but all that is really treated is the right g56.01 and only and xray of the right side Which the appropriate code to use.

 

[LisaAlonso23]

1) When the patient is receiving treatment for the injury, the 7th character should be an A. A is for active treatment. The D would be the 7th character for aftercare, such as therapy, during healing/recovery.

2) If the patient has carpal tunnel bilaterally, but only the right is treated, you would code G56.03. The condition exists bilaterally at this point.
When/if the patient receives treatment for the left wrist, you would code that encounter as G56.02. At the time of the procedure on the left, the condition is no longer bilateral.