Neurology & Pain Management Coding Alert
CTS Diagnosis Coding
Question: Our physician recently performed a level-two evaluation and management (E/M) service for a new patient with a diagnosis of bilateral carpal tunnel syndrome (CTS) in her upper limbs. I was going to report two ICD-10 codes to indicate the left- and right-sided CTS, but someone in the office said there was a better, single-code option. Is this true? Oregon Subscriber Answer: Your colleague is correct; there is now a single-code option for bilateral CTS. On the claim, report 99202 (Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: an expanded problem focused history; an expanded problem focused examination; straightforward medical decision making …) for the E/M with G56.03 (Carpal tunnel syndrome, bilateral upper limbs) appended to represent the bilateral CTS. New development: The G56.03 option has only been around since October, when ICD-10 2017 premiered. Before ICD-10 2017, you only had the following codes for CTS:
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