Of late, some carriers are pending payment of CTS injections and requesting documentation to see if other treatments have failed.
Although, you the orthopedist have more than likely tried treatments such as splints, medication or OT/PT prior to injecting, the patient in some cases, may present to you as a new patient and request the injection at this first visit. Whatever the scenario, your documentation should include the previous therapies tried and failed either prescribed by you or the patient’s PCP.

Remember to indicate that the patients symptoms are worsening and also document a positive Tinel’s sign and/or a positive Phalen’s maneuver.

Examples of what to include in the documentation may look something like this:

• Nighttime wrist splint therapy began_________
• Weekly PT sessions, strength and stretching regime began__________
• Steroidal therapy began _______________
• Patients states____________did not help and symptoms began to become worse____________

Your diagnosis, ICD-9 – 354.0 – will become G56.00 with ICD-10.