ICD-10 Coding for Left Neck Pain(M54.21, M50.122, S13.4XXA)
Complete ICD-10-CM coding and documentation guide for Left Neck Pain. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Left Neck Pain
M50-M54Primary Range
Other Dorsopathies
This range includes codes for cervicalgia and cervical disc disorders, which are relevant for coding left neck pain.
Dislocation and sprain of joints and ligaments of cervical spine
This range is relevant for coding traumatic neck injuries, which may present as left 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 |
|---|---|---|---|
| M54.21 | Cervicalgia, occipito-atlanto-axial region, left | Use when the patient presents with isolated left-sided neck pain without neurological involvement. |
|
| M50.122 | Cervical disc disorder at C5-C6 level with radiculopathy, left | Use when there is confirmed radiculopathy with imaging evidence of disc disorder. |
|
| S13.4XXA | Sprain of ligaments of cervical spine, initial encounter | Use for acute traumatic neck pain with documented mechanism of injury. |
|
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 left neck pain
Essential facts and insights about Left Neck Pain
Primary ICD-10-CM Codes for left neck pain
Decision Criteria
clinical Criteria
- Pain strictly in the left cervical region without radiation.
documentation Criteria
- Documentation must specify left-sided pain and absence of neurological symptoms.
Applicable To
- Localized left neck pain
Excludes
- Cervical disc disorders with radiculopathy (M50.1-)
Clinical Validation Requirements
- Localized pain in the left cervical region
- No neurological deficits
- No identifiable structural pathology
Code-Specific Risks
- Risk of undercoding if radiculopathy is present but not documented.
Coding Notes
- Ensure laterality is specified in documentation.
M50.122 - Cervical disc disorder at C5-C6 level with radiculopathy, left
Use when there is confirmed radiculopathy with imaging evidence of disc disorder.
Applicable To
- Radiculopathy due to cervical disc disorder
Excludes
- Cervicalgia without radiculopathy (M54.2-)
Clinical Validation Requirements
- Imaging showing left C5-C6 disc protrusion
- Positive EMG/NCS for left C6 radiculopathy
Coding Notes
Ensure documentation includes imaging and EMG/NCS results.
S13.4XXA - Sprain of ligaments of cervical spine, initial encounter
Use for acute traumatic neck pain with documented mechanism of injury.
Applicable To
- Acute neck sprain from trauma
Excludes
- Chronic neck pain (M54.2-)
Clinical Validation Requirements
- Documented traumatic event
- Ligament-specific findings on examination
Coding Notes
Ensure trauma and mechanism are clearly documented.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Chronic pain due to trauma
G89.21Other symptoms involving nervous system
R29.818Car occupant injured in collision with fixed or stationary object, initial encounter
V43.5AXADifferential 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 Left Neck Pain to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code M54.21.
Impact
Clinical: May lead to incorrect treatment plans., Regulatory: Non-compliance with ICD-10 guidelines., Financial: Potential for claim denials or reduced reimbursement.
Mitigation Strategy
Always document the side of the body affected., Use templates that prompt for laterality.
Impact
Reimbursement: May result in lower reimbursement due to lack of specificity., Compliance: Non-compliance with ICD-10 coding guidelines., Data Quality: Decreases accuracy of clinical data.
Mitigation Strategy
Use M54.21 to specify left-sided neck pain.
Impact
Reimbursement: Claims may be denied without supporting documentation., Compliance: Non-compliance with payer requirements., Data Quality: Inaccurate representation of clinical condition.
Mitigation Strategy
Ensure all diagnostic tests are documented when coding M50.122.
Impact
Failure to document laterality can lead to audit findings.
Mitigation Strategy
Implement documentation checks to ensure laterality is always specified.
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 Left Neck Pain, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Left Neck Pain
Use these documentation templates to ensure complete and accurate documentation for Left Neck Pain. These templates include all required elements for proper coding and billing.
Emergency Department Visit for Left Neck Pain
Specialty: Emergency MedicineRequired Elements
- Pain location and quality
- Onset and duration
- Associated symptoms
- Neurological examination
- Imaging results
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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