Revenue Cycle Insider

Question: A patient came to the office complaining of lower back pain. The physician documented that the patient had strained a tendon in their lower back. Do I document the symptom that brought them to the encounter or the documented cause?

Oklahoma Subscriber

Answer: Always code to the documentation — and query if the documentation doesn’t tell you what you need to know.

In this case, look up low back pain, and you’ll find code M54.5 (Low back pain) and an Exlcudes1 note. The Exlcudes1 note says that low back strain should be coded specifically, which would take you to S39.012 (Strain of muscle, fascia and tendon of lower back).

You’ll need a 7^th character to fully code this diagnosis: Coders should use the appropriate character to document whether the encounter is the initial (A) or subsequent (S) encounter, or a sequela (S).

It’s important to rely on the documentation: If the strain was affecting a ligament or joint in the lumbar spine or pelvis, you’d be shuttled to the S33.- (Dislocation and sprain of joints and ligaments of lumbar spine and pelvis) codes due to an Excludes1 note on S39.012-. If the provider doesn’t specify the specific body part affected, you can query so you can make the most appropriate code selection.

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