Cervicalgia
ICD-10 M54.2 is a billable code used to indicate a diagnosis of cervicalgia.
Cervicalgia refers to pain in the cervical region of the spine, commonly known as neck pain. This condition can arise from various causes, including muscle strain, degenerative disc disease, herniated discs, or cervical spondylosis. Patients often present with localized pain, stiffness, and sometimes radiating symptoms into the shoulders or arms. The pain may be acute or chronic, and it can significantly impact daily activities and quality of life. Cervicalgia can also be associated with other conditions such as dorsalgia (back pain) and sciatica, where nerve root involvement leads to pain radiating down the arms or legs. Management of cervicalgia typically begins with conservative treatments, including physical therapy, medications (such as NSAIDs), and lifestyle modifications. In cases where conservative management fails, surgical options may be considered, such as discectomy or spinal fusion. Accurate diagnosis and treatment planning are crucial for effective management and recovery.
Detailed history of present illness, physical examination findings, imaging results, and treatment plans.
Patients presenting with neck pain after trauma, degenerative changes, or chronic pain syndromes.
Ensure documentation reflects the severity and duration of symptoms to justify surgical interventions.
Comprehensive assessment of functional limitations, treatment goals, and progress notes.
Patients undergoing rehabilitation for neck pain post-injury or surgery.
Documenting the effectiveness of conservative treatments is crucial for coding and billing.
Used for patients undergoing physical therapy for cervicalgia.
Documentation of the patient's progress and specific exercises performed.
Physical therapists should document the rationale for chosen exercises.
Performed when conservative management fails and a herniated disc is confirmed.
Detailed operative report and pre-operative evaluations.
Surgeons must document the necessity of surgery based on conservative treatment outcomes.
The primary treatment for cervicalgia typically involves conservative management, including physical therapy, pain medications, and lifestyle modifications. Surgical options are considered only if conservative treatments fail.
