Carpal tunnel syndrome
ICD-10 G56.0 is a billable code used to indicate a diagnosis of carpal tunnel syndrome.
Carpal tunnel syndrome (CTS) is a common condition that arises from the compression of the median nerve as it travels through the carpal tunnel in the wrist. This tunnel is a narrow passageway made up of bones and ligaments, and when it becomes narrowed or inflamed, it can lead to symptoms such as pain, numbness, tingling, and weakness in the hand and fingers. The condition is often associated with repetitive hand movements, such as typing or assembly line work, and can also be exacerbated by conditions like diabetes, hypothyroidism, and pregnancy. Diagnosis typically involves a thorough clinical examination, patient history, and may include nerve conduction studies (NCS) to assess the function of the median nerve. Treatment options range from conservative measures, such as splinting and corticosteroid injections, to surgical intervention in more severe cases. Understanding the pathophysiology of CTS is crucial for effective management and coding, as it often overlaps with other neuropathies and nerve entrapments.
Detailed neurological examination findings, including sensory and motor function assessments.
Patients presenting with numbness and tingling in the hands, especially those with a history of repetitive strain.
Ensure that nerve conduction studies are documented and interpreted correctly to support the diagnosis.
Surgical notes if surgical intervention is performed, including pre-operative and post-operative assessments.
Patients requiring surgical release of the carpal tunnel due to severe symptoms.
Document the rationale for surgical intervention and any conservative treatments attempted.
Performed when conservative treatments fail and symptoms are severe.
Pre-operative assessment, surgical notes, and post-operative follow-up.
Orthopedic surgeons must document the necessity of surgery based on symptom severity and prior treatments.
Common symptoms include numbness, tingling, and pain in the thumb, index, middle, and part of the ring finger, often worsening at night.
Diagnosis is typically made through a combination of clinical examination, patient history, and nerve conduction studies to assess median nerve function.
Treatment options range from conservative measures like wrist splinting and corticosteroid injections to surgical release in more severe cases.
