# Bilateral Carpal Tunnel-Aftercare



## Xlade (Oct 8, 2015)

So I just want to be sure, both because my providers are the most confusing bunch of people on the face of the earth and because ICD-10 is kicking my behind. I have a lady whose initial visit with us was in mid September. She was diagnosed with bilateral carpal tunnel and a ganglion cyst on her left wrist. Last week or so of September she had surgery on the right wrist. Today she came in for the follow up visit for that surgery. My wonderful, lovely nurse practitioner looked her over and listed a diagnosis of Bilateral Carpal Tunnel Syndrome and Ganglion Cyst of the Left Wrist (I'm going from memory here, as I've been home from work for hours). 

So obviously she's still got the CTS in the left wrist, and the cyst, but the right wrist should be gone. So I wouldn't code that right? Would I sequence the Z code for aftercare first?  Or the other two (which are going under the knife here in the next couple weeks). 

And no, talking to the provider about how they dictate their diagnosis won't work. They do this sort of thing on EVERY single post op and attempting to talk sense into them is a bit like trying to talk sense to a...well, I can't think of a good analogy.  We're hoping to have an educator soon to help. 

Anyways, thanks in advance!


----------



## talton0206 (Oct 14, 2015)

You are exactly right.  I have the same problem with my providers coding resolved conditions as active problems.  However, in order to remain in compliance with the guidelines, you can only code from the documentation.  Coders can not interpret the documentation.  Is this a billable visit?  If the decision for the bilateral surgery was made prior to the first surgery and there was not a significant event in the patient's interval history that necessitated starting over, I would code this as a non-billable post-op visit.  Otherwise, a clinical documentation clarification (a written request from the coder that is not leading and does not imply the answer) will have to be entered into the medical record to code only the left carpal tunnel.


----------

