ICD-10 Code M54.2
What is the code M54.2?
M54.2 is a billable/specific ICD-10-CM code used to denote "Cervicalgia," commonly known as neck pain. This code falls under the chapter of diseases of the musculoskeletal system and connective tissue, specifically category M54 Dorsalgia. It is applicable for both clinical diagnosis and billing purposes. Detailed description of M54.2
M54.2 addresses pain localized in the cervical (neck) area, which can vary from mild discomfort to severe pain. It is a common complaint that may involve persistent or acute discomfort in the neck area, potentially affecting mobility and quality of life.
Symptoms commonly associated with M54.2
Symptoms of cervicalgia might include:
- Persistent or intermittent neck pain
- Stiffness in the cervical region
- Reduced range of motion in the neck
- Pain that might radiate to the shoulders or upper back
- Tenderness in the neck area
Related and similar ICD-10-CM codes
Related ICD-10-CM codes that might also be considered depending on the specific clinical findings include:
- M50.90 (Cervical disc disorder, unspecified, unspecified cervical region): For neck pain specifically associated with disc pathology.
- M54.12 (Radiculopathy, cervical region): If the neck pain is due to nerve root compression.
- M54.40 (Lumbago with sciatica, unspecified side): For cases where lower back pain radiates to the lower limbs.
Appropriate usage of M54.2 for billing
M54.2 should be used for billing purposes when a provider lists a patient's symptoms of neck pain that do not stem from intervertebral disc disorders or any other underlying condition in the assessment portion of their note. This code may apply to a variety of clinical settings, including general practice, orthopedics, and physical therapy.
Instructional guidelines for providers coding M54.2
When coding with ICD-M54.2, providers should document the pain's duration (acute or chronic), intensity, and precise location. This detailed documentation distinguishes cervicalgia from other causes of neck pain and ensures effective management and appropriate reimbursement.
Code M54.2 includes a type 1 excludes note, which specifies that it should not be used in conjunction with:
- Cervicalgia due to intervertebral cervical disc disorder (M50.-). If the patient is diagnosed with this condition, only the appropriate M50 code should be used.
- Psychogenic dorsalgia (F45.41). If cervicalgia is related to psychological disorders, only the F45.41 code should be assigned.
Additionally, M54.2 may be used alongside codes from category G89, which describe whether the pain is acute or chronic. The use of M54.2 in conjunction with a G89 code should be based on the specific details of the clinical encounter, allowing for a more nuanced description of the pain’s nature.
Common pitfalls in coding with M54.2
- Misclassifying neck pain related to disc disorders under M54.2.
- Failing to update the diagnosis if the provider lists a more specific diagnosis in the assessment portion of a note
Key resources for M54.2 coding
- CMS ICD-10 Homepage: A resource for updates and comprehensive guidelines on ICD-10-CM coding.
- WHO ICD-10 Online Browser: Useful for verifying ICD-10-CM codes and their descriptions.
Conclusion
The ICD-10-CM code M54.2 is used for accurately documenting cases of neck pain, facilitating appropriate treatment and billing. Understanding and correctly applying this code supports effective patient management, ensuring compliance with healthcare reporting requirements.
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