ICD-10 Coding for Right Neck Pain(M54.2, M50.11, M54.12, S13.4XXA)
Complete ICD-10-CM coding and documentation guide for Right Neck Pain. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Right Neck Pain
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 for isolated right-sided neck pain without neurological findings. |
|
| M50.11 | Cervical disc disorder with radiculopathy, right side | Use when there is imaging evidence of disc pathology with radicular symptoms. |
|
| M54.12 | Cervical radiculopathy, right side | Use when radiculopathy is present without evidence of disc disorder. |
|
| S13.4XXA | Sprain of ligaments of cervical spine, initial encounter | Use for acute traumatic sprain of cervical ligaments. |
|
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 right neck pain
Essential facts and insights about Right Neck Pain
Primary ICD-10-CM Codes for right neck pain
Decision Criteria
clinical Criteria
- Right-sided neck pain without radiation or neurological findings
Applicable To
- Right-sided neck pain without neurological findings
Excludes
- Cervical disc disorders with radiculopathy (M50.1-)
Clinical Validation Requirements
- Documentation of right-sided neck pain
- Absence of neurological symptoms
Code-Specific Risks
- Overuse when more specific codes are applicable
Coding Notes
- Ensure documentation specifies laterality to avoid unspecified codes.
M50.11 - Cervical disc disorder with radiculopathy, right side
Use when there is imaging evidence of disc pathology with radicular symptoms.
Applicable To
- Right cervical disc herniation with radiculopathy
Excludes
- Cervicalgia without radiculopathy (M54.2)
Clinical Validation Requirements
- MRI showing right-sided disc herniation
- EMG confirming radiculopathy
Coding Notes
Ensure documentation includes specific neurological findings.
M54.12 - Cervical radiculopathy, right side
Use when radiculopathy is present without evidence of disc disorder.
Applicable To
- Right-sided cervical radiculopathy without disc disorder
Excludes
- Cervical disc disorder with radiculopathy (M50.1-)
Clinical Validation Requirements
- Dermatomal sensory loss
- Positive neurological tests
Coding Notes
Document specific neurological findings to support code use.
S13.4XXA - Sprain of ligaments of cervical spine, initial encounter
Use for acute traumatic sprain of cervical ligaments.
Applicable To
- Acute right cervical ligament sprain
Excludes
- Fracture of cervical spine (S12.-)
Clinical Validation Requirements
- Mechanism of injury
- X-ray/MRI ruling out fracture
Coding Notes
Document trauma mechanism and rule out fractures.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Differential Codes
Alternative codes to consider when ruling out similar conditions to the primary diagnosis.
Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting Right 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: May lead to incorrect treatment, Regulatory: Non-compliance with coding standards, Financial: Potential for denied claims
Mitigation Strategy
Always specify the side of the neck affected.
Impact
Clinical: Inaccurate diagnosis, Regulatory: Non-compliance with coding guidelines, Financial: Lower reimbursement rates
Mitigation Strategy
Ensure imaging confirms radiculopathy before coding.
Impact
Reimbursement: May lead to lower reimbursement, Compliance: Non-compliance with coding guidelines, Data Quality: Inaccurate data on trauma-related pain
Mitigation Strategy
Code G89.11 first, then M54.2
Impact
Reimbursement: May result in use of unspecified codes, Compliance: Non-compliance with laterality requirements, Data Quality: Loss of specificity in patient records
Mitigation Strategy
Query provider to specify right/left/bilateral
Impact
Failure to document laterality can lead to audit flags.
Mitigation Strategy
Implement mandatory laterality fields in EHR templates.
Impact
Coding radiculopathy without supporting documentation increases audit risk.
Mitigation Strategy
Require imaging and neurological documentation before coding.
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 Right Neck Pain, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Right Neck Pain
Use these documentation templates to ensure complete and accurate documentation for Right Neck Pain. These templates include all required elements for proper coding and billing.
Acute Right Neck Pain Post-Trauma
Specialty: Emergency MedicineRequired Elements
- Mechanism of injury
- Pain location and severity
- Neurological examination
- Imaging results
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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