Neck Pain ICD-10 Codes: What Providers Need to Know

Healthcare professionals play a crucial role in managing and coding for neck pain, ensuring accurate documentation and effective treatment. Neck pain is a common condition seen by physical and occupational therapists, affecting 30% to 50% of adults in the general population in any given year. Approximately 50%–85% of individuals with neck pain continue to suffer, and some may go on to experience chronic, impairing pain. Over a twelve-month period, prevalence estimates for activity-impairing neck pain range from 3.1% to 4.5% in the general population. Like chronic low back pain (LBP), chronic neck pain is challenging to treat. In cases related to work injury, neck pain may cause absenteeism as frequently as LBP.

ICD Primer for Physical and Occupational Therapists

Physical and occupational therapists must use ICD-10 codes if they work in a HIPAA-covered entity, regardless of whether they manage a cash practice or receive insurance payments. ICD-10-CM stands for the International Classification of Diseases, 10th Revision, Clinical Modification, and is the system used by providers to code diagnoses for illness and injury. It’s a standard code, allowing for better communication between providers of different teams and specialties and ensuring it’s easily understood by Medicare and insurance companies, who use it to determine the medical necessity of various treatments. It can also be helpful to track and assess outcomes across a large population or to receive reimbursement for treatments provided.

Here is an example illustrating the various portions of that code that you’ll use in your practice.

ICD-10 Code Structure

• Characters 1-3 = The category of the diagnosis
• Characters 4-6 = Etiology, anatomic site, severity, or other clinical details
• Characters 7 = Extension

EXAMPLE – The following example shows the more detailed information gained as characters are added.

•             S52 Fracture of forearm
•             S52.5 Fracture of lower end of radius
•             S52.52 Torus fracture of lower end of radius
•             S52.521 Torus fracture of lower end of right radius
•             S52.521A Torus fracture of lower end of right radius, initial encounter

In the above example, S52 is the category.  The fourth and fifth characters of “5” and “2” provide additional clinical detail and anatomic site.  The sixth character (1) indicates laterality, i.e., right radius.  The seventh character, “A,” is an extension that, in this example, means “initial encounter.”

The 5th and 6th character sub-classifications represent the most accurate level of specificity.  

Understanding the Primary Code: M54.2 (Cervicalgia)

Symptoms of Neck Pain

Neck pain can present with numerous symptoms and vary from person to person. These symptoms can help you select the appropriate ICD-10 code for your patient. They include:

• Dull, sharp, or burning pain in the cervical spine
• Pain that radiates to the upper back, shoulders, arms, forearms, or hands
• Pain that radiates to the occiput (back) of the skull
• Numbness or tingling in arms, forearms, or hands
• Pain or stiffness with neck movement

Cervical disc degeneration is another condition that can be coded using specific ICD-10 codes, emphasizing the need for accurate and specific medical billing.

The primary code, M54.2, is most commonly used for discomfort or pain in the posterior or lateral cervical region. If it’s lasted more than three months it’s considered chronic, and less than three months is considered acute. Code M54.2 is billable, but other codes may offer a more accurate description of the patient’s condition.

ICD 10 Codes for Neck Pain

M50 – Cervical disc disorders

One specific condition for neck pain involves the intervertebral disc. Healthcare providers utilize ICD-10 codes for accurate documentation and treatment planning. If this is the case for your patient, you may consider the following codes.

• M50.00 (Cervical disc disorder with myelopathy): This code indicates damage to one or more intervertebral discs in the cervical spine.
• M50.01 (Cervical disc disorder with myelopathy, high cervical region)
• M50.02 (Cervical disc disorder with myelopathy, mid-cervical region): Code M50.020 refers to cervical disc disorder with myelopathy but no specified level. Other codes under this one can indicate a given level, such as C4-C5.
• M50.03 (Cervical disc disorder with myelopathy, cervicothoracic region)
• M50.10 (Cervical disk disorder with radiculopathy): This code refers to disc disorders that cause pain involving nerve entrapment, causing pain that radiates down the arm. As with M50.02, subsequent codes under this one can indicate whether the level is high or mid-cervical.
• M50.20 (Cervical disc displacement, unspecified cervical region): Used when one of the cervical discs is displaced, causing pain and possible nerve impingement.

G54.2 – Cervical root disorders, not elsewhere classified

This code is for conditions that involve the nerve roots and cause symptoms such as neck pain, weakness, or numbness. Due to irritation or damage, these symptoms may extend to the arms or hands. Diagnosis often involves clinical exam history and imaging studies such as CT or MRI scans.

M53.1 – Cervicobrachial syndrome

Changes in the cervical spine can cause discomfort in the arms and hands. This condition involves both the cervical spine and the brachial plexus. Its causes are various and include cervical disc herniation, cervical radiculopathy, cervical spondylosis, and damage to the brachial plexus.

Physical therapy is often recommended as a treatment option for cervicobrachial syndrome.

S13.4 – Sprain and strain of cervical spine

Cervical sprains occur when the ligaments in the neck are overstretched. Unlike strains, cervical sprains can take months to heal. When coding for these sprains, be as specific as possible, such as, “sprain of the anterior longitudinal ligament.”

M45.0 – Ankylosing spondylitis

Ankylosing spondylitis is a chronic inflammatory arthritis that affects the axial joints of the spine. Symptoms include stiffness in the spine and swelling between vertebrae. Over time, it can cause the vertebrae to fuse, causing the spine to lose flexibility and lead to a hunched posture. Its subdivisions pinpoint the affected area: occipito-atlanta-axial, cervical, or cervicothoracic.

M48.0 – Spinal stenosis

Spinal stenosis can occur in the center of the spine, in the canals off of the spine, or between the vertebrae. It can cause pain, numbness, or weakness. Like M45.0, subsequent coding will indicate the cervical area for more specificity.

This list is not extensive, but it illustrates some of the more common codes seen by therapists treating patients with neck pain.

The Seventh Character

As mentioned above, a seventh character for your codes is possible. This is one of the biggest changes of ICD-10 versus ICD-9. Many will not need to use this character, but physical and occupational therapists (PTs and OTs) will see it in one particular area: injuries.

There has been confusion about the use of this character, but to keep it simple, this article will focus on the top three: A, D, and S. 

A is used for the initial encounter. The patient actively receives treatment for the injury or condition. This can include surgery, an ER visit, or treatment by a new physician. In general, PTs and OTs will not use this character. They will, however, use . . .

D is used for subsequent encounters after the patient has undergone the initial treatment. This is the primary seventh character used by PTs and OTs.

S is used for sequelae – conditions or complications that have resulted from the initial injury. One of the more common sequelae outside of rehab therapy is a burn scar. The S code is applied to the condition or injury that caused the sequelae.

Example:

Using the code for cervical sprain, here are some of the possible codes using the seventh character:

• S13.4XXA – Sprain of cervical spine ligaments during initial encounter
• S13.4XXS – Sprain of cervical spine ligaments as a sequelae
• S13.4XXD – Sprain of cervical spine ligaments seen in a subsequent encounter

External Cause Codes

With injury codes, there are often external cause codes that help describe how the initial injury occurred. These codes answer one of the following questions:

• How did the injury occur?
• Where did it happen?
• What was the patient doing when it happened?
• Was it intentional or unintentional?

These only need to be reported for the initial visit. Here is an example that illustrates how many of these codes can apply to a single individual.

You have a patient who strained their Achilles tendon while running on a treadmill at a gym. For this set of circumstances, you would need an activity external cause code, a place of occurrence code, and an external cause status code.

In this case, the activity code would be Y93.A1 (running on a treadmill); the place of occurrence code would be Y92.39 (gym); and the external cause status code would be Y99.8 (recreating or sport not for income or while a student).

So, in this example, you would submit four ICD-10 diagnosis codes to accurately describe how the patient presented with an Achilles tendon sprain in their right foot, an injury the patient suffered while recreationally running on a treadmill at a gym. Here are the four codes:

• S86.011D = Strain of right Achilles tendon, subsequent encounter
• Y93.A1 = Activity, exercise machines primarily for cardiorespiratory conditioning, treadmill
• Y92.39 = Gymnasium as a place of occurrence of the external cause
• Y99.8 = Recreation or sport not for income or while a student

These codes are contained in chapter 20 of the ICD-10, titled “External Causes of Morbidity.” While these codes are not mandatory, they add to the specificity of your patient’s injury. As we’ve mentioned here and in many of our other ICD-10 references, specificity is your friend. The more specific you can be, the better.

Other ICD-10 Pearls for Therapists

In addition to the above items, particular aspects are important for physical therapists.

1. Chapter 19 contains codes for external causes such as injuries and poisonings. Chapter 13 also contains several codes related to the musculoskeletal system and connective tissue. Most of these codes have site and laterality built into the description of the patient’s condition.
2. Multiple-site diagnoses, such as osteoarthritis, have predefined multiple-site codes. If there are no such codes, each site should be coded separately.
3. Pay attention to bone versus joint coding differences. Even if the condition affects the end of the bone and involves the joint, the site coded is still the bone.
4. Many conditions treated by PTs and OTs result from a previous injury or trauma and are recurrent conditions. Chapter 13 contains codes for most recurrent bone, joint, or muscle conditions. Injury codes for acute conditions will come primarily from Chapter 19.

Neck Pain ICD-10 Coding Best Practices

If ICD-10 codes are new to you, the process may seem overwhelming initially, but following a few simple rules can avoid claim denials and headaches with billing. Be as specific as possible when choosing the codes, and in particular, be diligent in your documentation to support using those codes.

Choose a physical therapy EMR that has built in compliance features to more easily ensure you’re documenting properly. Understanding ICD-10 can take continued efforts to maintain the right processes, especially with the advent of ICD-11 on the horizon. Finally, remember that consistent and thorough coding will assist your practice and your patients, so staying informed is worth the time and effort.orizon. Finally, remember that consistent and thorough coding will assist your practice and your patients, so staying informed is worth the time and effort.