Wiki "needs to be Clinically Correlated" do you code it?

[KMoose]

Wondering if you code things that "need to be clinically correlated"?

In this case it's 'bilateral carpal tunnel syndrome, mild to medium severity, left worse than right, which needs to be clinically correlated given that symptoms are worse on the right'.

I've been reading articles online about this term and find that quite a few providers don't like its overuse. However, that has nothing to do with whether we code it or not.

Is it considered one of those terms where we would instead code the signs/symptoms?

 

[Bernadette10]

I would code bilateral carpal tunnel syndrome. I read this as the patient has it on both sides, but the severity is what needs to be clinically correlated since it looks like a test was done that showed the LT side worse, but the symptoms show the RT side worse.