Neurosurgery Coding Alert

Question: My surgeon treated a patient complaining of neck pain. The encounter notes indicated that the patient’s final diagnosis is a neck sprain. Which ICD-10-CM code should I report for this procedure? encounter?

Nebraska Subscriber

Answer: You may need a little bit more information to select the most accurate code. First, you’ll need to 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 ligaments of unspecified parts of neck)

Note: Each of these codes requires a seventh character to note encounter status: A (Initial encounter), D (Subsequent encounter), or S (Sequela).

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. You should also add a code from Chapter 20 to describe how the neck sprain happened if known (i.e., W06. xxxA, Fall from bed, initial encounter).