Primary Care Coding Alert

Question: Our provider treated a patient for a sore neck after the patient was involved in a motor vehicle accident (MVA). If I use an external cause code for the MVA, do I have to use an injury code for the neck pain? Or should I use M54.2?

AAPC Forum Participant

Answer: Chapter-specific guideline 1.C.13.b. tells you that “chronic or recurrent conditions should generally be coded with a code from chapter 13,” but “any current, acute injury should be coded to the appropriate injury code from chapter 19.” This suggests an injury code more accurately describes the acute nature of the patient’s current condition in this encounter and that a musculoskeletal code is more appropriate for conditions that affect the patient over an extended period of time.

However, that does not necessarily mean you should code the patient’s condition with a code such as S16.1XXA (Strain of muscle, fascia and tendon at neck level, initial encounter), because the guideline also goes on to tell you that “if it is difficult to determine from the documentation in the record which code is best to describe a condition, query the provider.”

Consequently, in this encounter, you will definitely have to work with your provider to determine whether S16.1XXA or M54.2 (Cervicalgia) is the appropriate way to code the patient’s neck pain along with the appropriate code fromV40-V49 (Car occupant injured in transport accident) for the MVA.