by Wyn Staheli, Director of Content - innoviHealth
Nov 30th, 2017 - Reviewed/Updated Feb 5th
Question
In order to code carpal tunnel syndrome G56.01 or G56.02, does there need to be documentation that nerve conduction (EMG testing) has been performed to confirm the diagnosis?
Answer
Really it depends on the normal medical diagnostic practices as well as the requirements of the payer. For CTS, there are physical exam findings (non EMG testing) which support the diagnosis and typically providers say "these symptoms with this patient history = carpal tunnel syndrome" so it would be appropriate as long as the physical exam findings support it.
However, if there is a need for more extensive procedures such as surgery, it is necessary to find out what the patient's insurance payer requires, which may be further testing to confirm the physical exam findings.
About Wyn Staheli, Director of Content - innoviHealth
Wyn Staheli is the Director of Content Research for innovHealth. She has over 30 years of experience in the healthcare industry. With her degree in Management Information Systems (MIS), she has been a programmer for a large insurance carrier as well as a California hospital system. She is also the author and editor of many medical resource books and the founder of InstaCode Institute.
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