Pain Management Coding Alert

Question: After performing a level-three evaluation and management (E/M) service for a new patient, the provider documents “involuntary movement, muscle” as a diagnosis. Is this specific enough to file as a diagnosis?

North Carolina Subscriber

Answer: You probably don’t have enough information to choose the correct ICD-10 code for this claim.

Why? The code grouping for abnormal involuntary movements, R25.- (Abnormal involuntary movements), requires a fourth digit to specify the type of movement. Here are the fourth-digit options for R25.-:

• R25.0 — Abnormal head movements
• R25.1 — Tremor, unspecified
• R25.2 — Cramp and spasm
• R25.3 — Fasciculation
• R25.8 — Other abnormal involuntary movements
• R25.9 — Unspecified abnormal involuntary movements.

Do this: Go back and check the notes for more detail on the type of involuntary movement the patient displayed. If it isn’t in the notes, ask the performing provider point blank about the movement type. Then, you’ll have all the information to choose the correct ICD-10 code for your 99213 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: An expanded problem focused history; An expanded problem focused examination; Medical decision making of low complexity …) claim. 

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