Pain Management Coding Alert

Question: Our provider recently provided an evaluation and management (E/M) service to an established patient complaining of neck pain. Encounter notes indicate that the final diagnosis is “neck sprain.” What is the correct ICD-10 code for this encounter?

Alabama Subscriber

Answer: You’ll need a bit more information in order to choose the most correct code possible. To report the correct code, first 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 ligament 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), says Peggy Stilley, CPC, CPC-I, CPMA, CPB, COGBC, revenue integrity auditor for Oklahoma Sports Orthopedics Institute in Norman.

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 as to how the neck sprain happened if known (i.e., W06.XXXA, Fall from bed, initial encounter).