ICD-10 Coding for Cervical Facet Syndrome(M53.82, M54.2, M47.812)
Complete ICD-10-CM coding and documentation guide for Cervical Facet Syndrome. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Cervical Facet Syndrome
Code Comparison: When to Use Each Code
Compare key differences between these codes to ensure accurate selection
| Code | Description | When to Use | Key Documentation |
|---|---|---|---|
| M53.82 | Other specified dorsopathies, cervical region | Use when cervical facet syndrome is confirmed by clinical and imaging findings. |
|
| M54.2 | Cervicalgia | Use for general neck pain without specific diagnosis of facet syndrome. |
|
| M47.812 | Cervical spondylosis without myelopathy or radiculopathy | Use when spondylosis is the primary finding. |
|
Clinical Decision Support
Always review the patient's clinical documentation thoroughly. When in doubt, choose the more specific code and ensure documentation supports it.
Key Information: ICD-10 code for cervical facet syndrome
Essential facts and insights about Cervical Facet Syndrome
Primary ICD-10-CM Codes for cervical facet syndrome
Decision Criteria
clinical Criteria
- Presence of localized cervical tenderness and imaging evidence of facet degeneration.
documentation Criteria
- Documented failure of conservative treatments and positive diagnostic block results.
Clinical Validation Requirements
- Localized cervical tenderness
- Imaging showing facet degeneration
- Positive response to diagnostic blocks
Code-Specific Risks
- Incorrectly using a more general code like M54.2 for specific facet syndrome.
Coding Notes
- Ensure documentation supports the specific diagnosis of cervical facet syndrome.
M54.2 - Cervicalgia
Use for general neck pain without specific diagnosis of facet syndrome.
Excludes
- Cervical facet syndrome (M53.82)
Clinical Validation Requirements
- Generalized neck pain
- No specific facet joint involvement
Coding Notes
Ensure pain is nonspecific and not attributable to facet syndrome.
M47.812 - Cervical spondylosis without myelopathy or radiculopathy
Use when spondylosis is the primary finding.
Excludes
- Cervical facet syndrome (M53.82)
Clinical Validation Requirements
- Osteophytes on imaging
- Disc space narrowing
Coding Notes
Ensure imaging supports spondylosis diagnosis.
Differential Codes
Alternative codes to consider when ruling out similar conditions to the primary diagnosis.
Cervicalgia
M54.2Cervical spondylosis without myelopathy or radiculopathy
M47.812Other specified dorsopathies, cervical region
M53.82Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting Cervical Facet Syndrome to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code M53.82.
Impact
Clinical: May lead to misdiagnosis., Regulatory: Non-compliance with documentation standards., Financial: Potential claim denials.
Mitigation Strategy
Always include imaging results in documentation., Ensure findings correlate with clinical symptoms.
Impact
Reimbursement: May lead to incorrect reimbursement rates., Compliance: Could result in non-compliance with coding guidelines., Data Quality: Affects accuracy of clinical data.
Mitigation Strategy
Use M53.82 when facet syndrome is confirmed.
Impact
Incomplete documentation of injection levels and imaging findings.
Mitigation Strategy
Implement thorough documentation protocols and regular audits.
Documentation errors, coding pitfalls, and audit risks are interconnected aspects of medical coding and billing. Addressing all three areas helps ensure accurate coding, optimal reimbursement, and regulatory compliance.
Frequently Asked Questions
Common questions about ICD-10 coding for Cervical Facet Syndrome, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Cervical Facet Syndrome
Use these documentation templates to ensure complete and accurate documentation for Cervical Facet Syndrome. These templates include all required elements for proper coding and billing.
Cervical Facet Syndrome Diagnosis
Specialty: Pain ManagementRequired Elements
- Patient history of neck pain
- Physical exam findings
- Imaging results
- Response to diagnostic blocks
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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