Find information on neck sprain diagnosis, including clinical documentation, ICD-10 codes (S13.4xxA, S13.4xxD), medical coding guidelines, and treatment options. Learn about whiplash-associated disorders, cervical strain, acute neck pain, and related symptoms for accurate healthcare record keeping. This resource helps medical professionals ensure proper documentation and coding for neck sprains.
Also known as
Sprain of cervical spine
Sprains of neck ligaments causing pain and limited motion.
Dislocation, sprain, and strain of joints and ligaments of neck
Includes various neck injuries like dislocations, sprains, and strains.
Injuries to the head
While less specific, neck sprains can be associated with head injuries.
Dorsalgia
Neck sprain can cause back pain, sometimes classified as dorsalgia.
Follow this step-by-step guide to choose the correct ICD-10 code.
Is the neck sprain traumatic?
Yes
Current injury?
No
Is there inflammation?
When to use each related code
Description |
---|
Neck sprain |
Whiplash injury |
Cervical strain |
Coding neck sprain as unspecified (S13.9) when more specific documentation like laterality or degree is available, leading to inaccurate severity capture.
Incorrectly coding whiplash (S13.4) as a simple neck sprain or vice versa, potentially impacting reimbursement and quality metrics.
Lack of specific documentation regarding the cause, location, and severity of the neck sprain hinders accurate code assignment and audit defense.
Patient presents with complaints of neck pain and stiffness, consistent with a neck sprain or whiplash injury. Onset of symptoms occurred following [Mechanism of injury - e.g., motor vehicle accident, fall, sudden movement]. Patient reports [Severity - e.g., mild, moderate, severe] pain localized to the [Location - e.g., cervical spine, paraspinal muscles, upper back] with associated [Symptoms - e.g., muscle spasms, limited range of motion, headaches, radiating pain to shoulders or arms]. Pain is aggravated by [Aggravating factors - e.g., movement, palpation, prolonged sitting] and relieved by [Relieving factors - e.g., rest, ice, over-the-counter pain medication]. Physical examination reveals [Objective findings - e.g., tenderness to palpation, muscle spasm, decreased range of motion in flexion, extension, lateral rotation, lateral bending]. Neurological examination is [Neurological findings - e.g., intact, with no evidence of radiculopathy or myelopathy]. Differential diagnoses include cervical strain, facet joint syndrome, disc herniation. Impression is neck sprain (ICD-10 code S33.6). Treatment plan includes [Treatment - e.g., rest, ice, heat therapy, NSAIDs, muscle relaxants, physical therapy, cervical collar]. Patient advised to follow up in [Follow-up duration - e.g., one week, two weeks] to assess response to treatment. Patient education provided regarding proper posture, ergonomics, and activity modification. Prognosis is good with conservative management.