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Question: I鈥檓 reading encounter notes for a patient who presented with neck pain after an energetic dancing and headbanging session with their 10-year-old child. The patient didn鈥檛 seek care initially, thinking the pain would resolve in a day or two, but is now worried that there may be a fracture or some other serious condition. The provider performed an exam and ordered an X-ray, and determined that the patient has a neck sprain. Which diagnosis codes should I report?

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Answer: To properly code a neck sprain, you need to know which components 鈥� ligaments or joints 鈥� are implicated by the sprain. You may need to query the physician to get the level of specificity necessary.

Once you have that information, you鈥檒l need a code from the S13.- category (Dislocation and sprain of joints and ligaments at neck level), which requires a 4^th character.

According to Codify, this code includes these situations:

• 鈥淎vulsion of joint or ligament at neck level
• 鈥淟aceration of cartilage, joint or ligament at neck level
• 鈥淪prain of cartilage, joint or ligament at neck level
• 鈥淭raumatic hemarthrosis of joint or ligament at neck level
• 鈥淭raumatic rupture of joint or ligament at neck level
• 鈥淭raumatic subluxation of joint or ligament at neck level
• 鈥淭raumatic tear of joint or ligament at neck level.鈥�

So, if the notes indicate that a patient presents with neck pain for the first time and the provider diagnoses a sprain of the cervical spine ligaments, you鈥檇 report S13.- for the encounter. You may also need to add a code to describe how the neck sprain happened, if known, such as Y93.4 (Activities involving dancing and other rhythmic movement).

As for coding the rest of the encounter, you鈥檒l report the appropriate evaluation and management (E/M) code from the 99202 (Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/ or examination and straightforward medical decision making. When using total time on the date of the encounter for code selection, 15 minutes must be met or exceeded.) through 99215 (Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and high level of medical decision making. When using total time on the date of the encounter for code selection, 40 minutes must be met or exceeded.) series, along with the code for the X-ray.

Go back and check the documentation to determine the specific X-ray code, because several codes are options based on the description you provided.

Rachel Dorrell, MA, MS, CPC-A, CPPM, Development Editor, AAPC