ED Coding and Reimbursement Alert

Question: The ED provider treated a patient who came in complaining of neck pain that’s been getting worse ever since the patient fell out of bed last month. She says she initially thought it would resolve on its own, but now she’s worried that maybe there’s a spinal fracture. After an examination and an X-ray, the ED physician determines that the patient is suffering from a neck sprain. Which diagnosis codes apply?

Michigan Subscriber

Answer: You may have to get a little bit more information to select the most accurate code. First, you’ll need to find out which ligaments or joints were sprained in the neck.

Your options include:

• S13.4xx- (Sprain of ligaments of cervical spine)
• S13.8xx- (Sprain of joints and ligaments of other parts of neck)
• S13.9xx- (Sprain of joints and ligaments of unspecified parts of neck)

Note: Each of these codes requires a 7th character to note encounter status: A (Initial encounter), D (Subsequent encounter), or S (Sequela).

So, if the notes indicate that a patient presents with neck pain for the first time (which is the likeliest situation in the ED and based on the description of the encounter), and the provider diagnoses a sprain of the cervical spine ligaments, you’d report S13.4xxA for the encounter. You should also add a code from Chapter 20 to describe how the neck sprain happened if known (i.e., W06.xxxA, Fall from bed, initial encounter). In addition, you’ll report the appropriate evaluation and management (E/M) code from the 99281-99285 series, along with the code for the X-ray, unless the X-ray was performed by hospital staff on hospital equipment.