Orthopedic Coding Alert

Question: The provider treated a patient who came in complaining of neck pain that’s been getting worse ever since the patient fell out of bed last month. She says she initially thought it would resolve on its own, but now she’s worried that maybe there’s a spinal fracture. After an examination and an X-ray, the physician determines that the patient is suffering from a neck sprain. Which diagnosis codes apply?

Florida Subscriber

Answer: You may have to get a little bit more information to select the most accurate code. First, you’ll need to find out which ligaments or 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 7th 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).

In addition, you’ll report the appropriate evaluation and management (E/M) code from the 99202 (Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/ or examination and straightforward medical decision making. When using time for code selection, 15-29 minutes of total time is spent on the date of the encounter.) through 99215 (Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and high level of medical decision making. When using time for code selection, 40-54 minutes of total time is spent on the date of the encounter.) series, along with the code for the X-ray.

Go back and check the notes for the proper X-ray code, as there are several that could be in play based on your description.