Anesthesia Coding Alert

Heads up: Don’t ignore categories with associated signs and symptoms.

A patient who suffers from carpal tunnel syndrome (CTS) is experiencing a compression neuropathy. This compression can lead to 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.

When you still assigned diagnoses based on ICD-9, you had a single code for CTS: 354.0 (Carpal tunnel syndrome). Now ICD-10 allows you to report the patient’s condition with more clarity, with separate codes for unspecified upper, right, and left limbs, as follows:

• G56.00 – Carpal tunnel syndrome, unspecified upper limb
• G56.01 – Carpal tunnel syndrome, right upper limb
• G56.02 – Carpal tunnel syndrome, left upper limb.

Coder tips: 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.” Also, ICD-10 directs you to 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:

• M25.539 – Pain in unspecified wrist
• M25.531 – Pain in right wrist
• M25.532 – Pain in left wrist.

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.