September 10, 2015

Question:

I noticed that the ICD-10 carpal tunnel syndrome diagnosis codes are specific for right and left. What happens if the patient has bilateral carpal tunnel syndrome – how should I code it?

Answer:

Good question, because many ICD-10-CM codes have right, left and bilateral codes; although the codes for carpal tunnel syndrome do not have a bilateral option. Here’s what we’ve got in ICD-10-CM for carpal tunnel syndrome:

G56.01 Carpal tunnel syndrome, right upper limb
G56.02 Carpal tunnel syndrome, left upper limb

But there is not a code for bilateral carpal tunnel syndrome. So if the patient has bilateral carpal tunnel syndrome, you will use both ICD-10-CM codes: G56.01 and G56.02.

*This response is based on the best information available as of 09/10/15.