Causalgia of bilateral upper limbs

This code signifies a diagnosis of causalgia affecting both the patient's upper extremities. Causalgia, also known as complex regional pain syndrome type II (CRPS II), is a chronic neuropathic pain condition characterized by severe burning pain, allodynia, and hyperalgesia, typically following a nerve injury. The bilateral designation indicates that both arms are experiencing these symptoms.

Apply this code when documentation explicitly states a diagnosis of causalgia or CRPS II involving both the right and left upper limbs. This typically follows a confirmed injury to a major peripheral nerve in each arm. Supporting documentation should detail the characteristic burning pain, sensory abnormalities, and the bilateral distribution.

• Ensure documentation clearly specifies "bilateral" involvement of the upper limbs; otherwise, a unilateral code (G56.41 or G56.42) would be more appropriate.
• Distinguish from CRPS type I (reflex sympathetic dystrophy), which does not involve a confirmed nerve injury and is coded with G90.5x.
• Code any underlying nerve injury or trauma separately, if applicable, as an additional diagnosis.