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Neurology & Pain Management Coding Alert

READER QUESTIONS:

2 Ways to Code Complaint From Past Injury

Published on Fri Sep 18, 2009

Question: We have a patient with previous injury to the spine that is now causing neck pain. How should I code the diagnosis? North Carolina Subscriber Answer: Document and code prior conditions that contribute to a patient's current complaint -- if they affect the management of the current condition. Prior trauma, such as a previously broken bone or other injury, can cause patients to experience back pain. If the patient's pain stems from a previous condition, you may code that diagnosis to justify pain management procedures your neurologist performs. Depending on the situation, there may be late-effect codes or V codes that you may report in addition to the current complaint that show a late effect or a personal history of trauma. Option 1: If the patient's chronic neck pain is documented as due to a prior traumatic vertebral fracture -- at C2-C3, for instance -- you could code this as: • 338.21 -- [...]
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