Question: A patient reported to the ED complaining of pain in his entire left leg; he said the pain had been nearly constant for a week, and was aggravated by walking and standing. He rated his pain as a seven on a scale of 10. Encounter notes indicated that the ED provider performed an examination and came to a final diagnosis is pain in the left leg. The ED physician instructed the patient on care, and told him to follow up in two weeks with a pain management specialist if the patient didn’t subside.
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Answer: On this claim, you’d report M79.605 (Pain in left lower limb NOS) along with the most appropriate E/M code. However, since this is an “NOS” code (not otherwise specified), you should be sure that the documentation doesn’t include additional details that could steer your toward a different code instead. For instance, if the patient said the pain began after he fell off a curb, you might add a secondary code to describe the cause of the injury.
