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M54.6
ICD-10-CM
Left-Sided Rib Pain

Experiencing left-sided rib pain? Learn about potential causes, including intercostal neuralgia, costochondritis, pleurisy, rib fractures, and cardiac issues. This resource provides information on diagnosis codes (ICD-10), clinical documentation tips for healthcare professionals, and differential diagnosis considerations for left-sided rib pain. Explore symptoms, treatment options, and when to seek medical attention for left-sided chest pain and rib cage discomfort.

Also known as

Left Rib Cage Pain
Left Thoracic Pain

Diagnosis Snapshot

Key Facts
  • Definition : Pain felt on the left side of the chest, often related to the ribs, muscles, or nerves.
  • Clinical Signs : Sharp, aching, or stabbing pain; tenderness to touch; worsened by breathing or movement.
  • Common Settings : Trauma, muscle strain, costochondritis, shingles, or pleurisy. May occur in outpatient or emergency settings.

Related ICD-10 Code Ranges

Complete code families applicable to AAPC M54.6 Coding
M99.8x

Other biomechanical lesions

Includes other specified biomechanical lesions not classified elsewhere.

R07.1

Chest pain, unspecified

Encompasses chest pain not otherwise specified.

M79.6

Pain in thoracic spine

Pain localized to the thoracic spine region.

Code-Specific Guidance

Decision Tree for

Follow this step-by-step guide to choose the correct ICD-10 code.

Is the rib pain traumatic in origin?

  • Yes

    Rib fracture confirmed?

  • No

    Is there intercostal neuralgia?

Code Comparison

Related Codes Comparison

When to use each related code

Description
Left-sided rib pain
Costochondritis
Pleurisy

Documentation Best Practices

Documentation Checklist
  • Left-sided rib pain: Location, quality, radiation
  • Onset, duration, frequency of left rib pain
  • Associated symptoms: cough, dyspnea, fever
  • Physical exam findings: tenderness, swelling, crepitus
  • Diagnostic tests ordered & results (CXR, ECG)

Coding and Audit Risks

Common Risks
  • Unspecified Laterality

    Coding rib pain without specifying left side can lead to inaccurate reimbursement and data analysis. Use specific ICD-10 codes for left-sided pain.

  • Underlying Cause Missing

    Coding only rib pain without the underlying cause (e.g., fracture, intercostal neuralgia) impacts DRG assignment and quality reporting. Document and code etiology.

  • Trauma vs. Non-Trauma

    Distinguishing between traumatic and non-traumatic rib pain is crucial for accurate coding and injury severity tracking. Document mechanism of injury if applicable.

Mitigation Tips

Best Practices
  • Thorough HPI vital for accurate ICD-10 coding, compliant billing.
  • Document specific rib location, palpation findings for CDI best practices.
  • Correlate pain with respiration, exertion for precise diagnosis coding.
  • R/O cardiac causes, document EKG/labs for compliant left rib pain diagnosis.
  • MSK vs. visceral origin impacts coding, justify medical necessity clearly.

Clinical Decision Support

Checklist
  • Rule out cardiac causes: ECG, troponin (ICD-10 I20-I25)
  • Assess for pleuritic pain: Auscultate lungs (ICD-10 J90, R09.1)
  • Palpate ribs for fracture/costochondritis (ICD-10 M94.0, M94.1)
  • Consider shingles: Check dermatomes (ICD-10 B02)

Reimbursement and Quality Metrics

Impact Summary
  • Left-Sided Rib Pain: Medical Billing, Coding, ICD-10, Reimbursement, Hospital Revenue Cycle
  • Impact: Accurate ICD-10 coding (e.g., rib fracture, intercostal neuralgia) maximizes reimbursement.
  • Impact: Precise documentation supports medical necessity, reducing claim denials.
  • Impact: Proper coding impacts quality metrics related to pain management and respiratory health.

Streamline Your Medical Coding

Let S10.AI help you select the most accurate ICD-10 codes for . Our AI-powered assistant ensures compliance and reduces coding errors.

Quick Tips

Practical Coding Tips
  • Code specific rib location
  • Document injury details
  • Rule out cardiac causes
  • Consider intercostal neuralgia
  • Check ICD-10 guidelines

Documentation Templates

Patient presents with complaints of left-sided rib pain.  Onset, duration, character, aggravating factors, and relieving factors of the pain were explored.  Differential diagnoses considered include intercostal neuralgia, costochondritis, rib fracture, pleurisy, and musculoskeletal strain.  Patient denies any recent trauma or injury to the chest wall.  Review of systems was negative for fever, chills, cough, shortness of breath, or weight loss.  Physical examination revealed point tenderness along the left lateral rib cage at the [specify rib number(s)] level.  No crepitus or deformity was palpable.  Lung sounds are clear to auscultation bilaterally.  Cardiac examination is unremarkable.  Assessment:  Left-sided rib pain, likely musculoskeletal in etiology.  Plan:  Conservative management with nonsteroidal anti-inflammatory drugs (NSAIDs) for pain relief.  Patient education provided regarding proper posture, stretching exercises, and activity modification.  Follow-up recommended if symptoms persist or worsen.  ICD-10 code [Insert appropriate ICD-10 code, e.g., M79.1] may be considered depending on the final diagnosis.  CPT codes for the evaluation and management services provided will be documented according to the level of complexity.
Left-Sided Rib Pain - AI-Powered ICD-10 Documentation