Neurology & Pain Management Coding Alert

Question: Our pain management specialist is treating a patient for neck sprain. What is the best ICD-10 diagnosis for sprain in the cervical region?

New Mexico Subscriber

Answer: When you still coded with ICD-9, neck sprain and strain had a common code: 847.0 (Neck sprain) under category 847 (Sprains and strains of other and unspecified parts of back). Now, with ICD-10, you code for neck sprain using S13 (Dislocation and sprain of joints and ligaments at neck level). This code includes:

• Avulsion of joint or ligament at neck level
• Laceration of cartilage, joint or ligament at neck level
• Sprain of cartilage, joint or ligament at neck level
• Traumatic hemarthrosis of joint or ligament at neck level
• Traumatic rupture of joint or ligament at neck level
• Traumatic subluxation of joint or ligament at neck level
• Traumatic tear of joint or ligament at neck level. 

The code family expands to include groupings based on specific sites of injury. For example, the base codes that apply to other parts of the cervical regions include:

• S13.4XX_, Sprain of ligaments of cervical spine
• S13.5XX_, Sprain of thyroid region
• S13.8XX_, Sprain of joints and ligaments of other parts of neck.

The seventh character of the ICD-10 code should represent the level of encounter for that particular visit. You’ll report “A” for initial encounter, used to report active treatment of the sprain, “D” for subsequent encounter, used to indicate routine care during the healing or recovery phase of the sprain, or “S” for sequela, used to indicate a complication or condition that developed as a direct result of the neck sprain.