Carpal tunnel syndrome, unspecified upper limb
ICD-10 G56.00 is a billable code used to indicate a diagnosis of carpal tunnel syndrome, unspecified upper limb.
Carpal tunnel syndrome (CTS) is a common condition caused by 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. The condition can arise from various factors, including repetitive wrist movements, wrist injuries, and certain medical conditions like diabetes and hypothyroidism. Diagnosis typically involves a thorough clinical examination, patient history, and may include nerve conduction studies (NCS) to assess the function of the median nerve. These studies help confirm the diagnosis by measuring the speed of electrical impulses through the nerve, which can be slowed in cases of entrapment. Treatment options range from conservative measures, such as splinting and corticosteroid injections, to surgical intervention in more severe cases. Accurate coding is essential for proper reimbursement and to reflect the patient's condition in medical records.
Detailed neurological examination findings, including sensory and motor assessments.
Patients presenting with numbness and tingling in the hand, particularly after repetitive activities.
Ensure nerve conduction study results are documented and correlate with clinical findings.
Surgical notes if surgery is performed, including pre-operative assessments and post-operative care.
Patients requiring surgical intervention for severe carpal tunnel syndrome.
Document the rationale for surgical intervention and any conservative treatments attempted.
Used to confirm diagnosis of carpal tunnel syndrome.
Document the specific nerves tested and results.
Neurologists should ensure that the rationale for testing is clearly stated.
The primary symptom is numbness and tingling in the hand, particularly in the thumb, index, and middle fingers.
Diagnosis is typically made through clinical evaluation and confirmed with nerve conduction studies.
