ICD-10 Coding for Cervical Neck Pain(M54.2, M54.12)
Complete ICD-10-CM coding and documentation guide for Cervical Neck Pain. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Cervical Neck Pain
M50-M54Primary Range
Dorsopathies
This range includes disorders of the cervical spine, including cervicalgia and related conditions.
Code Comparison: When to Use Each Code
Compare key differences between these codes to ensure accurate selection
| Code | Description | When to Use | Key Documentation |
|---|---|---|---|
| M54.2 | Cervicalgia | Use when the patient presents with neck pain without radiculopathy or myelopathy. |
|
| M54.12 | Radiculopathy, cervical region | Use when cervical radiculopathy is confirmed by clinical findings and imaging. |
|
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 neck pain
Essential facts and insights about Cervical Neck Pain
Primary ICD-10-CM Codes for cervical neck pain
Decision Criteria
clinical Criteria
- Pain localized to the cervical region without radiation.
documentation Criteria
- Detailed physical exam findings supporting cervicalgia.
Applicable To
- Neck pain
Excludes
- Cervical disc disorders with radiculopathy (M50.1-)
Clinical Validation Requirements
- Localized tenderness in the cervical region
- Absence of neurological deficits
Code-Specific Risks
- Undercoding if radiculopathy is present but not documented.
Coding Notes
- Ensure documentation specifies the absence of radiculopathy to use M54.2.
M54.12 - Radiculopathy, cervical region
Use when cervical radiculopathy is confirmed by clinical findings and imaging.
Applicable To
- Cervical radiculopathy
Excludes
- Cervical disc disorders with radiculopathy (M50.1-)
Clinical Validation Requirements
- Radiating pain to the arm
- Positive Spurling’s test
Coding Notes
Ensure documentation includes neurological findings to support radiculopathy.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Acute pain due to trauma
G89.11Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting Cervical Neck Pain to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code M54.2.
Impact
Clinical: Leads to inappropriate treatment plans., Regulatory: Fails to meet documentation standards., Financial: May result in claim denials.
Mitigation Strategy
Use specific descriptors for pain., Document physical exam findings.
Impact
Reimbursement: Incorrect coding can lead to claim denials., Compliance: Non-compliance with coding guidelines., Data Quality: Inaccurate clinical data representation.
Mitigation Strategy
Use M54.12 when radiculopathy is present.
Impact
Failure to document neurological findings can lead to audit issues.
Mitigation Strategy
Ensure thorough documentation of neurological exams and imaging results.
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 Neck Pain, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Cervical Neck Pain
Use these documentation templates to ensure complete and accurate documentation for Cervical Neck Pain. These templates include all required elements for proper coding and billing.
Chiropractic SOAP Note
Specialty: ChiropracticRequired Elements
- Subjective pain description
- Objective physical exam findings
- Assessment and plan
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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