Orthopedic Coding Alert

Question: What is the difference between carpal tunnel syndrome (CTS) and wrist pain? Also, how should I report ICD-10 codes for each condition?

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Answer: Generally, pain in the wrist primarily involves pain in the wrist. The pain is localized to the wrist but might involve surrounding areas as well. Pain in the wrist might feature swelling, difficulty moving the wrist, and tenderness on palpation or with specific wrist movements.

You’ll report pain in the wrist with one of the following codes, depending on encounter specifics:

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

CTS could also involve all of the symptoms of pain in the wrist — but there will be more symptoms with CTS patients. Symptoms that could mean CTS include:

• Numbness and tingling: This could occur most often in the thumb, index, middle, and ring fingers.
• Weakness: A patient with CTS might also have difficulty with both fine motor tasks and dropping objects due to weakness.
• Worsening of symptoms at certain times: Patients with CTS are often awakened by the pain; others might see an increase in pain with activities that involve flexing or extending the wrist.

You’ll report CTS with one of the following diagnosis codes, depending on encounter specifics:

• G56.00 (Carpal tunnel syndrome, unspecified upper limb)
• G56.01 (Carpal tunnel syndrome, right upper limb)
• G56.02 (Carpal tunnel syndrome, left upper limb)
• G56.03 (Carpal tunnel syndrome, bilateral upper limbs)

Chris Boucher, MS, CPC, Senior Development Editor, AAPC