Internal Medicine Coding Alert

Question: Our provider recently provided an evaluation and management (E/M) service to an established patient complaining of neck pain. Encounter notes indicate that the final diagnosis is “neck sprain.” What is the correct ICD-10 code for this encounter?

Texas Subscriber

Answer: You’ll need a bit more information in order to choose the most correct code possible. To report the correct code, first find out which ligaments/joints were sprained in the neck.

Your options include:

• S13.4xx-,  Sprain of ligaments of cervical spine
• S13.8xx-, Sprain of joints and ligaments of other parts of neck
• S13.9xx-, Sprain of joints and ligament of unspecified parts of neck.

Note: Each of these codes requires a 7th character to note encounter status: A (initial encounter), D (subsequent encounter), or S (sequela), says Peggy Stilley, CPC, CPC-I, CPMA, CPB, COGBC, revenue integrity auditor for Oklahoma Sports Orthopedics Institute in Norman.

So, if the notes indicate that a patient presents with neck pain for the first time, and the provider diagnoses a sprain of the cervical spine ligaments, you’d report S13.4xxA for the encounter.

Also: Add a code from ICD-10’s “Chapter 20: External Causes of Morbidity” to reflect how the patient hurt his neck. for example, if he fell from the bed and hurt his neck, and this is his first visit to the pediatrician for treatment of the problem, report W06.XXXA (Fall from bed, initial encounter) along with the neck sprain code.

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