Musculoskeletal condition M54.02 — ICD-10 M54.02

ICD-10: M54.02 | Category: Spine Disorders | Billable: Yes

Cervical radiculopathy, classified under ICD-10 code M54.02, refers to a condition characterized by pain, weakness, or sensory disturbances that occur due to the compression or irritation of cervical nerve roots in the neck region. This condition often results from degenerative changes in the cervical spine, such as herniated discs or osteophyte formation. While cervical radiculopathy can affect either side of the body, this article specifically addresses left-sided symptoms and their implications for diagnosis and treatment.

The cervical spine consists of seven vertebrae (C1-C7) and is designed to support the head while allowing a wide range of motion. Each vertebra is separated by intervertebral discs that serve as shock absorbers. The spinal cord runs through the vertebral foramen, with nerve roots branching out from the spinal cord at each intervertebral foramen.

Key Anatomical Structures:

• Cervical Vertebrae (C1-C7): Provide structural support and protect the spinal cord.
• Intervertebral Discs: Composed of an outer annulus fibrosus and a gel-like nucleus pulposus; these discs help absorb shock and allow for movement.
• Nerve Roots: Emerge from the spinal cord and exit through the foramina, innervating specific regions of the upper extremities.

Biomechanics:

The cervical spine's biomechanics involve complex movements including flexion, extension, rotation, and lateral bending. These movements are facilitated by various muscles and ligaments that maintain stability while allowing mobility. However, excessive strain or degenerative changes can lead to nerve root compression, resulting in radiculopathy.

Patient presents with a 45-year-old female who reports persistent neck pain radiating to the shoulders for the past three months. The pain worsens with prolonged sitting and improves with rest. Upon examination, the provider notes muscle tenderness in the cervical region and restricted range of motion. Code as M54.02 because the documentation clearly indicates cervicalgia as the primary diagnosis, supported by the patient’s symptoms and clinical findings.

To support medical necessity for ICD-10 code M54.02 and prevent claim denials, the following documentation elements are critical:

• Comprehensive History and Examination: Document a thorough patient history, including duration, severity, and character of symptoms, as well as any aggravating and alleviating factors.

• Objective Findings: Record specific physical examination findings, including range of motion, tenderness, and neurological assessments that corroborate the diagnosis of cervicalgia.

• Treatment Plan: Clearly outline the treatment plan, including any referrals for physical therapy, imaging studies if warranted, and medications prescribed.

• Follow-up Documentation: Include notes on follow-up visits that assess the effectiveness of the treatment plan and any changes in the patient’s condition.

• Medical Necessity Justification: Ensure that the documentation justifies the need for services rendered based on the patient’s presenting symptoms and clinical findings.

Subjective: A 38-year-old male presents with complaints of neck pain that began two weeks ago after a long-distance driving trip. He describes the pain as sharp and intermittent, rating it a 6/10 in intensity. The pain radiates to the right shoulder and is aggravated by turning his head. Objective: Physical examination reveals tenderness in the cervical spine and limited range of motion, particularly with lateral flexion to the right. Neurological examination shows intact sensation and strength in the upper extremities. Assessment: M54.02 - Cervicalgia due to muscular strain likely related to prolonged positioning during driving. Plan:

• Recommend physical therapy focusing on neck strengthening and stretching exercises.
• Advise the use of ergonomic support while driving and during work.
• Prescribe NSAIDs for pain management as needed.
• Schedule a follow-up appointment in four weeks to assess progress.

Differentiating cervical radiculopathy from other conditions is crucial for effective management:

1. Cervical Spondylosis (M47.12): Degenerative changes without nerve root involvement.
2. Cervical Disc Degeneration (M51.36): Disc degeneration without radicular symptoms.
3. Thoracic Outlet Syndrome (G54.0): Compression of neurovascular structures at the thoracic outlet.
4. Peripheral Neuropathy (G62.9): Generalized nerve dysfunction not localized to cervical roots.
5. Brachial Plexus Injury (S14.0): Trauma-related nerve injury affecting multiple nerves.

Accurate documentation is critical for billing purposes:

Key Points for Documentation:

1. Clearly document patient history, physical examination findings, imaging results, and treatment plans.
2. Use specific ICD codes relevant to each patient's unique presentation to ensure proper billing (e.g., M54.02 for left-sided cervical radiculopathy).

Billing Guidance:

Ensure that all services provided are documented in accordance with payer guidelines, including any physical therapy sessions billed under CPT codes that correspond with the treatment provided.