tci ED Coding & Reimbursement Alert - 2010 Issue 4

Reader Questions: Document Traditional Tx Tries on Carpal Tunnel

Question: A 37-year-old librarian reports to the ED reporting pain at the base of her right radial wrist. She says about four days ago when she was stacking books, it started to ache. She had been using Ibuprofen to control the pain, but she says that it became unbearable yesterday; she reports an 8 on a 10-point pain scale. The ED physician exam reveals tenderness over the wrist; the patient exhibits a positive Tinel sign and is positive for carpal tunnel syndrome. During a level-three E/M service, the physician attempts to treat the patient's pain with anti-inflammatories, to no...

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