Bilateral Carpal Tunnel Syndrome ICD-10-CM Codes | 2023

What ICD-10 Codes are used for Bilateral Carpal Tunnel Syndrome

ICD-10 codes are essential for accurately documenting and coding medical conditions, including bilateral carpal tunnel syndrome (CTS). Here are the commonly used bilateral carpal tunnel syndrome ICD-10 codes, along with clinical descriptions for each:

• G56.01 - Carpal Tunnel Syndrome, Right Wrist: This code is used when carpal tunnel syndrome primarily affects the right wrist. It involves compression of the median nerve in the carpal tunnel, leading to pain, tingling, and numbness in the thumb, index, and middle fingers.
• G56.02 - Carpal Tunnel Syndrome, Left Wrist: Similar to G56.01, this code specifies that carpal tunnel syndrome predominantly affects the left wrist. It represents a compression of the median nerve on the left side, resulting in characteristic symptoms.
• G56.03 - Carpal Tunnel Syndrome, Bilateral: This code is specifically for bilateral carpal tunnel syndrome, indicating that the condition affects both wrists. Symptoms manifest in both hands due to compression of the median nerve in both carpal tunnels.
• G56.09 - Other Mononeuropathies of Right Upper Limb: Occasionally, carpal tunnel syndrome may be coded under this more general category when the focus is on the right upper limb. It includes other mononeuropathies that may affect the right arm.
• G56.19 - Other Mononeuropathies of Left Upper Limb: Similar to G56.09, this code is used when carpal tunnel syndrome predominantly affects the left upper limb, including the left arm and hand.
• M79.644 - Pain in Right Hand: This code is utilized when the primary symptom of bilateral carpal tunnel syndrome is pain, explicitly indicating pain in the right hand.
• M79.645 - Pain in Left Hand: Similar to M79.644, this code is used when pain is the primary symptom and specifies pain in the left hand.
• M70.02 - Other Soft Tissue Disorders Related to Use, Bilateral Forearm: In cases where soft tissue disorders are related to using both forearms, including carpal tunnel syndrome, this code may be applicable.
• M70.11 - Olecranon Bursitis, Right Elbow: Occasionally, symptoms of carpal tunnel syndrome may radiate, causing discomfort in the right elbow. This code is used for such cases.
• M70.12 - Olecranon Bursitis, Left Elbow: Similar to M70.11, this code is employed when carpal tunnel syndrome symptoms extend to the left elbow, leading to olecranon bursitis.

It's important to note that accurate coding requires detailed clinical documentation to ensure the appropriate code is selected for each patient encounter. Healthcare providers should use the most specific code that reflects the patient's condition and symptoms.

Which Bilateral Carpal Tunnel Syndrome ICD Codes are billable

Here's a breakdown of whether commonly used bilateral carpal tunnel syndrome ICD-10 codes are billable or not:

• G56.01 - Carpal Tunnel Syndrome, Right Wrist: Yes
• G56.02 - Carpal Tunnel Syndrome, Left Wrist: Yes
• G56.03 - Carpal Tunnel Syndrome, Bilateral: Yes
• G56.09 - Other Mononeuropathies of Right Upper Limb: Yes
• G56.19 - Other Mononeuropathies of Left Upper Limb: Yes
• M79.644 - Pain in Right Hand: Yes
• M79.645 - Pain in Left Hand: Yes
• M70.02 - Other Soft Tissue Disorders Related to Use, Bilateral Forearm: Yes
• M70.11 - Olecranon Bursitis, Right Elbow: Yes
• M70.12 - Olecranon Bursitis, Left Elbow: Yes

All the listed ICD-10 codes commonly used for bilateral carpal tunnel syndrome are billable. These codes are recognized and accepted for reimbursement when documenting and coding the medical billing and insurance claims diagnosis. 

However, it's crucial to ensure accurate and specific coding based on the patient's clinical presentation to facilitate proper reimbursement and avoid coding errors. To achieve accurate and billable code assignments, medical coders and healthcare providers should stay updated on coding guidelines and documentation requirements.

Clinical information

• Patients with bilateral carpal tunnel syndrome commonly experience pain, numbness, and tingling in the thumb, index, and middle fingers of both hands. These symptoms often worsen at night or during activities that involve repetitive hand movements.
• Clinical evaluation may reveal weakness in the affected hands, particularly in grip strength. Tapping on the median nerve (Tinel's sign) or holding the wrist flexed (Phalen's test) may elicit characteristic symptoms.
• Confirmation of bilateral carpal tunnel syndrome often involves nerve conduction studies and electromyography (NCS/EMG), which assess nerve function and muscle activity. These tests aid in determining the severity of nerve compression.
• The condition is frequently associated with factors such as repetitive hand movements, prolonged wrist flexion, obesity, pregnancy, and certain medical conditions like diabetes and rheumatoid arthritis.
• X-rays may be conducted to rule out other potential causes of hand pain, such as arthritis or fractures. Imaging is beneficial when there is uncertainty about the diagnosis.
• Initial treatment may involve wrist splints to keep the wrists in a neutral position, nonsteroidal anti-inflammatory drugs (NSAIDs) for pain, and modification of activities to reduce strain on the wrists.
• Therapeutic exercises and stretches to improve wrist strength and flexibility are often recommended. Physical therapists may also educate patients on ergonomic practices to minimize strain.
• Corticosteroid injections into the carpal tunnel may temporarily relieve symptoms by reducing inflammation and swelling around the median nerve.
• For cases resistant to conservative measures, surgical release of the carpal tunnel (carpal tunnel release) may alleviate pressure on the median nerve and improve symptoms.
• The prognosis for bilateral carpal tunnel syndrome is generally favorable with appropriate management. Early diagnosis and intervention often result in improved outcomes and relief from debilitating symptoms. Regular follow-up and adherence to recommended lifestyle modifications contribute to long-term success in managing the condition.

Synonyms include:

• Bilateral CTS
• Two-Sided Carpal Tunnel Disorder
• Dual Carpal Tunnel Affliction
• Both-Hand Carpal Tunnel Impairment
• Symmetrical Carpal Tunnel Neuropathy
• Recurrent Median Neuropathy in Both Wrists