Upper back pain ICD 10 code

Upper back pain ICD 10 code M54.6 is the closest code for pain in the thoracic spine. Back pain will be experienced by almost all individuals at some point in their lives. In most cases, back pain is short lived and self-limiting but for those individuals who have persisting pain, physical therapy is an excellent treatment option.

Much of the research on prevalence and impact of back pain is focused on low back pain, however, upper back pain can also cause a significant burden on financial, social and emotional resources for individuals. Upper back pain is often due to postural dysfunction but it can also be the result of an acute injury or due to repetitive motions performed in one’s job or daily life.

Symptoms of upper back pain can vary from person to person but may include the following:

• Dull, achy, sharp, or burning pain in the posterior upper thorax near the spine or on either side of it

• Pain that radiates around the front of the ribcage

• Pain in the upper back that is relieved or worsened by certain postures

• Pain in the low back that worsens with activity and improves with rest.

Because of its prevalence, you will likely encounter this condition frequently in your practice and understanding how to correctly utilize the ICD-10 code for upper back pain is imperative for minimizing insurance claim denials. If you, like many therapists, have some experience searching for and selecting ICD-10 codes but don’t have a good understanding of the who, what, when and why these codes are used, see the next section for an ICD-10 code primer. Following this introduction we will discuss the upper back pain ICD-10 code in more detail. 

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An Introduction to ICD-10 Codes

• Who: All HIPAA-covered entities are required to submit ICD-10 codes if seeking reimbursement for services from an insurance company, this includes physical therapists.

• What: The International Classification of Disease, 10th Revision (ICD-10) is a set of diagnosis, symptom, and procedure codes that physical therapists use daily in their practice. In 2015 physical therapists and all other HIPAA-covered healthcare providers transitioned from the ICD-9 to the current version, ICD-10. ICD-10 codes are alphanumeric codes. They begin with a letter and are always between three and seven characters with a decimal point placed after the third character.

The more characters it has, the more specific it is. Each code follows the following structure:

• Characters 1-3 indicate the category of the diagnosis

• Characters 4-6 indicate etiology, anatomic site, severity or other clinical detail

• Character 7 is an extension value, for example:
  • A: Initial encounter (anything related to care of the initial injury)
  • D: Subsequent encounter  (anything related to the phase of routine care of the injury while the patient recovers–this usually refers to rehabilitation)
  • S: Sequela (other conditions that may result from the presence of the primary condition)

Note, for fracture care, there are several more extensions (e.g.,  P, G, K, which signify malunion, delayed healing, or nonunion for a subsequent encounter).

When: ICD-10 codes must be submitted with relevant documentation whenever reimbursement is sought for covered services either by the healthcare entity itself or by a patient.

Why: While it may seem like an extra step in an already detailed process of documentation and billing, ICD-10 codes are required for a specific reason. Not only do they identify a medical diagnosis, but perhaps more importantly, they help insurance companies understand why the care you are providing is medically necessary and therefore, reimbursable.

What is the ICD-10 code for thoracic back pain?

M54.6 is the closest ICD-10 code for pain in the thoracic spine when treating a patient with pain located in the upper back. Like many conditions, you may not find the exact nomenclature you are looking for when searching for the corresponding ICD-10 code.

When selecting ICD-10 codes, the code with the highest number of applicable characters should be chosen, at least on the first visit. Many three- and even sometimes four-digit codes can be found for a given condition when searching a reputable database like ICD10 Data. In the case of the code M54.6, this is the most detailed code available.

M54.6: Pain in thoracic spine

M54.6 is used to describe acute or chronic pain in the thoracic spine, including the “upper back” region.

Synonyms for this code include:

• Chronic pain in thorax
• Chronic thoracic back pain
• Chronic thoracic pain
• Myofascial pain syndrome with lumbar involvement
• Thoracic facet joint pain
• Thoracic facet syndrome
• Thoracic spine pain

Is M54.6 billable?

M54.6 is considered specific enough and may be used for billing/reimbursement purposes.

How do I make M54.6 more specific?     

M54.6 is the most specific version of this code, meaning there are no longer versions of M54.6 for conditions within the category of “thoracic spine pain.” If there is a specific condition causing the upper back pain that you would like to bill for, look for some of the alternative codes below.

When is an alternative code more appropriate?

While M54.6 is considered a billable code, there may be times when you wish to include codes that identify the anatomical cause of pain. In this case you would need to look within a different code set. 

Here are some examples of useful ICD-10 codes to use when treating upper back pain.

Additional code considerations

While your treatment plan for addressing upper back pain may be complex, choosing the right ICD-10 code does not have to be difficult. To help you perfect your ICD-10 technique, however, here are some additional considerations to help with successful reimbursement:

“Non specific” or “other” code: whenever possible avoid using these codes as the primary diagnosis code if a more detailed and specific code is available

Place of occurrence codes (Y92): place of occurrence codes may be used during the initial evaluation to increase specificity of the primary diagnosis

• Examples 1: upper back pain after working in a daycare center

Y92.210: Daycare center as the place of occurrence of the external cause

• Example 2: upper back pain after riding roller coasters all weekend

Y92.831: Amusement park as the place of occurrence of the external cause

External cause codes (V00-Y99): specify an external cause resulting in the episode of upper back pain and may be used during the initial evaluation to increase specificity of the primary diagnosis

• Example 1: Passenger in a car accident

V43: Car occupant injured in collision with car, pick-up truck or van

• Example 2: Fall out of the bed

W06: Fall from bed