Neck Pain ICD 10 (M54.2): Key Information for Healthcare Providers
Healthcare professionals have an important job when it comes to handling and coding neck pain. They help with correct documentation and proper treatment. Neck pain is very common for physical and occupational therapists to treat. It affects 30% to 50% of adults every year. Around 50%–85% of people who get neck pain keep feeling it afterward, and some may even develop chronic (long-lasting) and limiting pain. In one year, about 3.1% to 4.5% of the population may suffer from neck pain that limits their activities. Like chronic low back pain (LBP), long-term neck pain is hard to treat. For people injured at work, neck pain may cause them to miss work just as often as back pain.
ICD Basics for Physical and Occupational Therapists
Physical and occupational therapists need to use ICD-10 codes if they work for any organization covered by HIPAA, even if they work with cash-paying patients or insurance. ICD-10-CM stands for International Classification of Diseases, 10th Revision, Clinical Modification. It’s the system used to list diagnoses for sickness and injury. These standard codes help different healthcare teams understand the diagnosis better. They also help Medicare and insurance companies decide if a treatment is needed. These codes are also used to track progress across many people or to get paid for the services given.
Here’s an example to help understand the code parts you’ll use in practice.
ICD-10 Code Structure
Characters 1-3 = Type of diagnosis
Characters 4-6 = Cause, body part, how bad it is, or other details
Character 7 = Extra detail
EXAMPLE – Here’s how adding more characters gives more specific information:
S52 Fracture of forearm
S52.5 Fracture of lower end of radius
S52.52 Torus fracture of lower end of radius
S52.521 Torus fracture of lower end of right radius
S52.521A Torus fracture of lower end of right radius, initial encounter
In this example:
S52 is the main diagnosis type.
4th and 5th characters (5 and 2) give more detail about the body part.
6th character (1) shows it’s the right side.
7th character (A) tells it’s the first visit for treatment.
The 5th and 6th characters give the highest level of detail.
Understanding the Main Code: M54.2 (Cervicalgia)
Neck Pain Symptoms
Neck pain can look different for each person. These signs help you pick the right ICD-10 code:
- Dull, sharp, or burning pain in the neck
- Pain going to upper back, shoulders, arms, or hands
- Pain reaching the back of the head
- Numb or tingling arms or hands
- Pain or stiffness when moving the neck
Cervical disc degeneration is another neck condition with its own ICD-10 codes. That’s why correct coding is very important.
The main code used is M54.2, which is for pain in the back or side of the neck. If the pain has lasted over three months, it’s chronic; less than that is acute. M54.2 is a valid code for billing, but other codes may better describe the condition.
ICD-10 Codes for Neck Pain
M50 – Cervical disc disorders
Some neck pain comes from problems with the disc between vertebrae. If that’s the case, here are codes you might use:
- M50.00 – Disc disorder with myelopathy
- M50.01 – High cervical region disc disorder with myelopathy
- M50.02 – Mid-cervical region disorder with myelopathy
- M50.03 – Cervicothoracic region disc disorder with myelopathy
- M50.10 – Disc disorder with radiculopathy, pain spreading to arms
- M50.20 – Disc is out of place (unspecified cervical region)
G54.2 – Cervical root disorders, not elsewhere classified
Used when nerve roots are affected, causing weakness or numbness in arms. A clinical exam or imaging is often used for diagnosis.
M53.1 – Cervicobrachial syndrome
When changes in the neck affect the arms and hands. Causes include herniated discs, radiculopathy, or spondylosis.
S13.4 – Sprain and strain of cervical spine
When neck ligaments are overstretched. Be specific when coding, like “sprain of anterior longitudinal ligament.
M45.0 – Ankylosing spondylitis
A long-term inflammatory arthritis affecting the spine. Can cause the spine to stiffen and bend forward. Codes tell what area is affected (upper spine, neck, etc.).
M48.0 – Spinal stenosis
Narrowing in the spine that causes pain or numbness. Later codes show if it’s in the neck.
These are not all the codes, but they’re the ones therapists see most often.
The Seventh Character
As we mentioned earlier, ICD-10 codes can include a seventh character, which is one of the major differences from ICD-9. Not all codes use this, but physical and occupational therapists will often see it with injuries.
To keep it simple, here are the most used ones:
- A = First time the patient is being treated (e.g., surgery, ER, or new doctor visit). PTs and OTs usually don’t use this.
- D = Follow-up visits after the first treatment. This is the one PTs and OTs use most.
- S = Used when a condition is the result of an earlier injury (called sequelae). Example: a scar from a burn.
Example:
Using the cervical sprain code:
- S13.4XXA = First visit
- S13.4XXS = Problem from an old injury
- S13.4XXD = Follow-up visit
External Cause Codes
In injury cases, you may need external cause codes to explain how it happened. These codes answer:
- How did the injury happen?
- Where did it happen?
- What was the person doing?
- Was it on purpose or an accident?
These are only needed for the first visit.
Example:
Someone hurt their Achilles tendon while running on a treadmill at the gym. You’ll need:
- S86.011D = Right Achilles tendon strain, follow-up
- Y93.A1 = Running on treadmill
- Y92.39 = Gym location
- Y99.8 = Recreational, not work or school
You’d use four ICD-10 codes in this case. These codes come from Chapter 20, called “External Causes of Morbidity.” They aren’t required, but they give more detail. The more specific your
Other ICD-10 Tips for Therapists
Here are extra tips for physical therapists:
- Chapter 19 has codes for injuries and poisonings.
- Chapter 13 has codes for bones and muscles. Many of them include the affected body part and side.
- For conditions like osteoarthritis, if there are codes that include more than one site, use them. If not, code each site separately.
- Be careful between bone vs. joint codes. If a joint is involved, but the issue is at the end of the bone, still code the bone.
- Many conditions PTs/OTs treat are from old injuries. Use Chapter 13 for those. Use Chapter 19 for new injuries.
Best Practices for Coding Neck Pain in ICD-10
If you’re new to ICD-10 codes, the process might feel confusing at first. But by following a few simple steps, you can avoid problems like claim denials and billing issues. Always pick the most specific codes, and make sure your documentation clearly supports the codes you use.
Use a physical therapy EMR that includes compliance tools to help you document correctly. Learning ICD-10 takes ongoing effort to keep your processes right, especially with ICD-11 coming soon. In the end, using codes consistently and carefully helps both your practice and your patients, so it’s worth staying up to date.
