ICD Code S13.4XXA

ICD code S13.4XXA is a medical classification used to indicate an initial encounter for a sprain of the ligaments in the cervical spine, which is the neck region of the spine. This code is part of the International Classification of Diseases, 10th Revision (ICD-10), and it helps healthcare providers document and communicate the specific type of injury for billing and treatment purposes.

1. Neck Pain: The patient presents with acute neck pain following a recent injury or trauma, such as a fall or car accident.

2. Limited Range of Motion: The patient experiences difficulty or pain when attempting to move the neck, indicating potential ligament involvement.

3. Swelling or Bruising: Visible swelling or bruising around the neck area, suggesting soft tissue damage.

4. Tenderness: Palpable tenderness over the cervical spine ligaments upon physical examination.

5. Muscle Spasms: The presence of involuntary muscle contractions in the neck region, often accompanying ligament sprains.

6. Headache: The patient reports headaches that may be associated with neck injury or strain.

7. Neurological Symptoms: Any signs of numbness, tingling, or weakness in the arms or hands, which may indicate nerve involvement due to the sprain.

8. History of Trauma: A documented history of a specific incident or accident that could have led to a cervical spine injury.

9. Radiological Evidence: Imaging studies, such as X-rays or MRIs, may be used to rule out fractures and confirm ligament sprain.

10. Initial Encounter: The patient is being evaluated for the first time for this specific injury, indicating the need for an initial encounter code.

For the ICD code S13.4XXA, which pertains to a sprain of ligaments of the cervical spine during an initial encounter, the relevant CPT codes that may be applicable include:

1. 99201-99205 - New patient office or other outpatient visit codes, depending on the level of service provided.

2. 99211-99215 - Established patient office or other outpatient visit codes, depending on the level of service provided.

3. 20552 - Injection(s); single or multiple trigger point(s), 1 or 2 muscle(s).

4. 97110 - Therapeutic exercises to develop strength and endurance, range of motion, and flexibility.

5. 97140 - Manual therapy techniques (e.g., mobilization/manipulation, manual lymphatic drainage, manual traction), one or more regions, each 15 minutes.

6. 97010 - Application of a modality to one or more areas; hot or cold packs.

7. 97035 - Application of a modality to one or more areas; ultrasound, each 15 minutes.

These CPT codes are examples of procedures and services that might be performed in the treatment of a cervical spine ligament sprain. The specific codes used will depend on the individual patient's treatment plan and the healthcare provider's clinical judgment. Always ensure that the chosen CPT codes accurately reflect the services provided and are supported by the patient's medical record documentation.

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