Wiki Coding carpal tunnel syndrome without EMG

[Sarahmk]

I'm a relatively new coder. Been working for an Internal Medicine office for over a year now. When I had first started, the office manager told me never to code carpal tunnel syndrome unless there was a positive EMG in the patient's chart. This was never an issue until now - I have a patient who the Dr. believes has CTS based on his exam findings (positive Phalen's, positive Tinel's). He is insisting on using the CTS code. Can I use the CTS dx without an EMG or must there be a positive nerve conduction study in order to effectively prove the diagnosis? PLEASE HELP.

 

[Ajesh Kuriakose]

We can code what the provider says, even if it lacks some tests if the provider specifies it is CTS you will have to code it. As long as the provider documents it as CTS you can code it.