Anesthesia Coding Alert

“Another challenge is distinguishing between different types of lower back pain such as sciatica, which describes pain radiating from the back into the buttock and leg along the sciatic nerve and is coded to M54.3-, versus lower back pain that’s not sciatica, which is coded to M54.5,” Moore adds.

That’s why “it is important to work with your provider to ensure that they provide you with the detailed information needed to code,” advises Chelle Johnson, CPMA, CPC, CPCO, CPPM, CEMC, AAPC Fellow, billing/credentialing/ auditing/coding coordinator at County of Stanislaus Health Services Agency in Modesto, California. “Wording such as ‘chronic,’ ‘upper,’ ‘lower,’ ‘injury,’ ‘initial,’ and ‘subsequent,’ for example, will all be needed to ensure that you select the most appropriate and exact code,” Johnson notes.

Zero in on the Best Code Family

The M54.- codes not only have their own problems, but the code group may not even contain the most specific code needed to describe a patient’s back pain diagnosis. To illustrate this, look at the following three scenarios and see how you would code them.

Scenario 1: A patient reports with back pain, and your provider documents that the patient has pain in the lumbar spine. Would you use M54.5 (Low back pain) or M54.9 (Dorsalgia, unspecified), which lists back pain not otherwise specified as a synonym?

Solution: “Dorsalgia is upper back pain, so M54.9 should not be selected,” cautions Johnson. Additionally, “M54.9 is an ‘unspecified’ code, which would not be appropriate in this situation, because the diagnosis is specific to lower back pain, for which a specific ICD-10-CM exists,” notes Moore. This means you would code M54.5 in this particular encounter.

Scenario 2: A patient reports with pain in the lower back. Your provider notes that the pain began when the patient tried to lift a heavy weight while at work. Would you use S39.012- (Strain of muscle, fascia and tendon of lower back) instead of M54.5?

Solution: “The answer here can be found in the difference between the words ‘pain’ and ‘strain,’ which is a stretching or tearing of a muscle or tendon caused by a traumatic injury, such as falling, lifting, or twisting,” according to Johnson.

“Had the physician diagnosed the patient with a lower back strain, then I’d go with S39.012-. But if the diagnosis is lower back pain, then M54.5 is the code to use. The fact the pain came from trying to lift a heavy weight doesn’t change that,” Moore advises.

Coding alert 1: “From an ICD-10-CM perspective, lower back pain and strain are mutually exclusive diagnoses, as there is an Excludes1 note under M54.5 directing coders to S39.012- for low back strain,” cautions Moore.

Scenario 3: Your provider documents that a patient has chronic lower back pain due to surgery or trauma.

Solution: Again, paying careful attention to your provider’s documentation, especially the word “chronic,” will guide you outside of the M54.- codes to a code from the G89.2 (Chronic pain, not elsewhere classified) group. Here you can pick from various codes:

• G89.21 (Chronic pain due to trauma) for chronic back pain due to trauma
• G89.28 (Other chronic postprocedural pain) for chronic back pain due to surgery
• G89.22 (Chronic post-thoracotomy pain) for chronic back pain due to thoracotomy, a surgery where a surgeon makes an incision between two ribs to gain access to organs such as the lungs that are located in the chest cavity, or thorax

Coding alert 2: Remember, ICD-10 does not place time parameters on chronic pain. Instead, the definition of “chronic” is up to provider documentation, and your coding should be based on that.