Neurology & Pain Management Coding Alert

Question: A new patient reported to the practice complaining of neck pain. After an evaluation and management (E/M) service that included an expanded problem focused history and examination, and straightforward medical decision making (MDM), the clinician arrived at a final diagnosis of “wry neck.” Then, then clinician performed trigger point injections (TPIs) in two of the patient’s neck muscles. Should I report the “wry neck” diagnosis for the E/M and the TPI? Also, what in the world is “wry neck”?

Florida Subscriber

Answer: First, wry neck is a term often used to describe torticollis. The correct ICD-10 code for wry neck is M43.6 (Torticollis). According to healthline.com, torticollis is “a painfully twisted and tilted neck. The top of the head generally tilts to one side while the chin tilts to the other side.”

Healthline.com also states that chronic wry neck can cause debilitating pain and difficulty performing daily tasks. Providers will often perform TPIs on wry neck patients in order to alleviate their symptoms.

(Note: If you don’t already know, check payer policy to see if M43.6 is a covered diagnosis for TPI before coding the encounter.)

Coding: On the claim, report 20552 (Injection[s]; single or multiple trigger point[s], 1 or 2 muscle[s]) for the TPI with M43.6 appended to represent the torticollis.

Then — provided you have clear evidence of a significant, separately identifiable E/M pre-TPI — report 99202 (Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: an expanded problem focused history; an expanded problem focused examination; straightforward medical decision making …) for the E/M service with modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) appended to show that you are coding for a separate E/M service in addition to the TPI.

And …: Since the clinician arrived at the torticollis diagnosis during the E/M service, you’ll also append M43.6 to 99202.