Neurosurgery Coding Alert

READER QUESTION ~ Consider Options for Myofascial Pain Dx

Question: Which diagnosis should I use for myofascial pain or myofascial discomfort?

South Carolina Subscriber

Answer: The ICD-9 index for -Pain, muscle- directs you to 729.1 (Myalgia and myositis, unspecified), so that should be your first consideration if the physician has not pinpointed a more specific diagnosis.

Depending on your neurosurgeon's documentation, however, you might be able to submit a diagnosis that's more specific to the patient's pain, such as 724.2 (Lumbago), if the physician states that the patient's pain is in the low back region.

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