Part B Insider (Multispecialty) Coding Alert

Tip: Determine whether prior conditions contribute to the patient's current complaint before you add the diagnosis codes.

Question: We have a patient with a previous injury to the spine that is now causing neck pain. How should I code the diagnosis?

Answer: Document and code prior conditions that contribute to a patient's current complaint -- if they affect the management of the current condition.

Prior trauma, such as a previously broken bone or other injury, can cause patients to experience back pain. If the patient's pain stems from a previous condition, you may code that diagnosis to justify pain management procedures your physician performs.

Depending on the situation, there may be late-effect codes or V codes that you may report in addition to the current complaint that show a late effect or a personal history of trauma.

Option 1: If the patient's chronic neck pain is documented as due to a prior traumatic vertebral fracture -- at C2-C3, for instance -- you could code this as:

• 338.21 -- Chronic pain due to trauma

• 723.1 -- Neck pain

• 905.1 -- Late effect of fracture of spine and trunk without mention of spinal cord lesion.

Option 2: If your provider's documentation does not include a "cause and effect" link to the current condition, you could code this scenario as 338.21, 723.1, and V15.51 (Personal history of injury, healed traumatic fracture).

Personal history "V codes" provide additional information to the payer indicating that the patient has had this condition or disease in the past but do not include any causality for the patient's current complaints.

The key to correctly coding these contributory conditions is making sure they are appropriately documented in the medical record. This information is central to justifying medical necessity.