Understanding axillary pain, also known as underarm pain or armpit pain, is crucial for accurate clinical documentation and medical coding. This resource provides information on diagnosing and documenting axillary pain, covering potential causes, associated symptoms, and relevant ICD-10 codes for healthcare professionals. Learn about the proper terminology and documentation practices for axillary pain to ensure accurate patient care and efficient medical coding.
Also known as
Pain in right axilla
Pain localized to the right armpit region.
Pain in left axilla
Pain localized to the left armpit region.
Pain, unspecified
Generalized pain without a specific location.
Myalgia
Muscle pain which could include the axillary region if specified elsewhere.
Follow this step-by-step guide to choose the correct ICD-10 code.
Is the axillary pain due to a direct injury or trauma?
Yes
Is there a fracture?
No
Is there lymphadenopathy?
When to use each related code
| Description |
|---|
| Pain in the armpit region. |
| Swollen lymph nodes in the armpit. |
| Inflammation of axillary sweat glands. |
Coding axillary pain requires specifying right, left, or bilateral. Unspecified laterality leads to coding errors and claim denials.
Axillary pain is a symptom. Coding should reflect the underlying diagnosis (e.g., lymphadenopathy, muscle strain) for accurate reimbursement.
Generalized pain coding lacks clinical detail. CDI should query for specifics to support more precise diagnoses and justify higher-level services.
Q: What are the key differential diagnoses for axillary pain radiating down the arm in a patient with a history of strenuous activity?
A: Axillary pain radiating down the arm, especially after strenuous activity, can indicate several conditions. Muscle strains or tears of the pectoralis major, latissimus dorsi, or rotator cuff muscles should be high on the differential diagnosis list. Nerve compression syndromes, such as thoracic outlet syndrome (TOS) or brachial plexus neuropathy, can also present with similar symptoms and should be considered, particularly if the patient reports numbness, tingling, or weakness. Furthermore, referred pain from the cervical spine or shoulder joint pathology needs to be ruled out. A thorough physical exam, including neurological assessment and range-of-motion testing, alongside imaging studies like X-rays or MRI if indicated, is crucial for accurate diagnosis. Explore how a comprehensive assessment can help differentiate these conditions and guide appropriate management.
Q: How can clinicians effectively differentiate between musculoskeletal and neurological causes of chronic axillary pain when evaluating a patient?
A: Distinguishing between musculoskeletal and neurological origins of chronic axillary pain requires a multi-faceted approach. Musculoskeletal causes, like rotator cuff tendinitis or frozen shoulder, often present with pain localized to the shoulder and axillary region, exacerbated by movement. Neurological causes, like brachial plexus neuropathy or intercostobrachial neuralgia, may involve sensory changes such as numbness, tingling, or burning sensations radiating down the arm. A detailed history focusing on the onset, character, and aggravating/relieving factors of the pain is essential. Specific physical examination maneuvers, such as Spurling's test for cervical radiculopathy or Roos test for TOS, can further aid in the differentiation. Electrodiagnostic studies, including nerve conduction studies and electromyography, may be necessary to confirm a neurological diagnosis. Consider implementing a structured evaluation protocol to streamline the diagnostic process for chronic axillary pain. Learn more about specialized tests for nerve entrapment syndromes.
Patient presents with complaints of axillary pain, also described as underarm pain or armpit pain. Onset of pain was [onset duration] and is characterized as [pain quality: e.g., sharp, dull, aching, burning, throbbing]. Pain severity is [pain scale rating, e.g., 4/10 on a numerical rating scale]. The pain is [pain frequency: e.g., constant, intermittent, episodic] and is [exacerbating/relieving factors: e.g., aggravated by movement of the arm, relieved by rest]. Patient denies any history of trauma, injury, or surgery to the affected area. Review of systems includes [relevant positive and negative findings]. Physical examination reveals [objective findings: e.g., tenderness to palpation in the axilla, palpable lymph nodes, limited range of motion]. Differential diagnosis includes but is not limited to muscle strain, lymphadenopathy, peripheral neuropathy, brachial plexus compression, and referred pain from the shoulder or neck. Diagnostic workup may include [diagnostic tests: e.g., complete blood count, ultrasound, mammogram, MRI]. Initial treatment plan consists of [treatment interventions: e.g., over-the-counter pain relievers, ice/heat therapy, rest, physical therapy referral]. Patient education provided regarding activity modification and follow-up care. Follow-up scheduled in [duration] to assess response to treatment and further evaluate if necessary. ICD-10 code considerations include [relevant ICD-10 codes: e.g., M79.601, R59.8, etc. based on exam findings]. Medical necessity for evaluation and treatment established based on patient's reported symptoms and clinical findings.