Neurology & Pain Management Coding Alert

Question: My neurologist has a patient who presented with tingling and pain in her right hand. He performed both motor and sensory nerve conduction studies and an EMG test. He documented possible carpal tunnel syndrome (CTS) as the final electrodiagnostic test findings and ordered a diagnostic ultrasound study to verify CTS. Should I just code for CTS as the diagnosis now to save time?

Texas Subscriber

Answer: No, you cannot report 354.0 (Carpal tunnel syndrome) in this case because your neurologist did not confirm CTS. You should only report signs and symptoms if your physician does not confirm CTS, or if the patient has additional symptoms that are not associated with CTS.

If the documentation supports it -- and to establish medical necessity for the diagnostic studies your neurologist has performed -- you would code the applicable signs and symptoms of CTS: numbness and tingling (782.0) aching pain in the thumb, index, and middle fingers that might move up the arm (729.5) hand and grip muscle weakness (728.87) feeling of swollen hand (729.81).

The ICD-9 guidelines state: "List first the ICD-9-CM code for the diagnosis, condition, problem, or other reason for encounter/visit shown in the medical record to be chiefly responsible for the services provided .... In some cases the first-listed diagnosis may be a symptom when a diagnosis has not been established (confirmed) by the physician. Do not code diagnoses documented as 'probable,' 'suspected,' 'questionable,' 'rule out,' or 'working diagnosis' or other similar terms indicating uncertainty. Rather, code the condition(s) to the highest degree of certainty for that encounter/visit, such as symptoms, signs,abnormal test results, or other  reason for the visit." You can access these required coding guidelines at: www.cdc.gov/nchs/data/icd9/icdguide09.pdf

Tip: You can code for the completed nerve conduction study (95900, Nerve conduction, amplitude and latency/velocity study, each nerve; motor, without F-wave study) with 95904 ( ... sensory) and the electromyography (EMG) test (95860, Needle electromyography; one extremity with or without related paraspinal areas).

If your physician diagnoses CTS after the diagnostic tests, you should not report signs and symptoms as secondary diagnoses. These are integral to the primary definitive diagnosis, so they don't need separate reporting. After you have conclusive test results, you can then report 354.0 (Carpal tunnel syndrome) as the primary diagnosis.