Neurosurgery Coding Alert

Question: If a patient suffers from myalgia, how do I choose an ICD-10-CM code? I’m new to neurosurgery coding, and I haven’t coded for a myalgia diagnosis.

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Answer: Hopefully, you’ll be able to glean the information you need from the operative notes. The diagnosis codes for myalgia are pretty straightforward; choose one of the following ICD-10-CM codes depending on encounter specifics:

• M79.10 (Myalgia, unspecified site)
• M79.11 (Myalgia of mastication muscle)
• M79.12 (Myalgia of auxiliary muscles, head and neck)
• M79.18 (Myalgia, other site)

Documentation alert: Choosing the correct ICD-10-CM code is your first task for this fibromyalgia patient. The second task is making sure the documentation includes as much information about the patient’s condition as possible. This information might not figure directly into the ICD-10-CM code selection, but it will help paint a more vivid picture of the patient’s condition and can influence quality of care in the future.

According to Cape Fear Valley Health in North Carolina, patients with myalgia should have the following information documented in the medical record:

• Note the specific location, such as shoulder, upper arm, forearm, hand, fingers, thigh, ankle, head, neck, mouth/jaw, etc.
• Detail when paralysis or burns accompany the calcification and ossification of muscles.
• Document any underlying disease, such as irritable bowel syndrome (IBS), rheumatoid arthritis (RA), temporomandibular joint (TMJ) disorder, etc.
• Document the laterality of the myalgia: right, left, or bilateral.

Chris Boucher, MS, CPC, Senior Development Editor, AAPC