Carpal tunnel syndrome, bilateral upper limbs
ICD-10 G56.03 is a billable code used to indicate a diagnosis of carpal tunnel syndrome, bilateral upper limbs.
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 syndrome is characterized by symptoms such as numbness, tingling, and weakness in the hand and fingers, particularly affecting the thumb, index, middle, and part of the ring finger. When CTS occurs bilaterally, it can significantly impact a patient's daily activities and quality of life. The condition is often associated with repetitive wrist movements, certain medical conditions (like diabetes and hypothyroidism), and anatomical variations. Diagnosis typically involves a thorough clinical evaluation, including a detailed history and physical examination, followed by nerve conduction studies (NCS) to assess the function of the median nerve. Treatment options may include conservative measures such as splinting, corticosteroid injections, and in some cases, surgical intervention to relieve pressure on the nerve. Accurate coding of G56.03 is essential for proper reimbursement and to reflect the severity and impact of the condition on the patient’s life.
Detailed neurological examination findings, results of nerve conduction studies, and treatment plans.
Patients presenting with numbness and tingling in the hands, especially those with a history of repetitive wrist use.
Ensure that all neurological assessments are documented, including any differential diagnoses considered.
Surgical notes if surgery is performed, pre-operative assessments, and post-operative follow-ups.
Patients requiring surgical intervention for severe carpal tunnel syndrome.
Document the rationale for surgical intervention and any pre-existing conditions that may affect recovery.
Used when surgical intervention is required for severe carpal tunnel syndrome.
Surgical notes, pre-operative assessments, and post-operative follow-ups.
Orthopedic surgeons should document the rationale for surgery and any complications.
Common symptoms include numbness, tingling, and weakness in the hands, particularly affecting the thumb, index, middle, and part of the ring finger. Symptoms may worsen at night or with repetitive wrist activities.
