Experiencing sternum pain? Learn about potential causes, including costochondritis, angina, and fractures. This comprehensive guide covers clinical documentation requirements, medical coding (ICD-10 codes for chest pain, sternal pain, and related diagnoses), and differential diagnosis considerations for healthcare professionals. Find information on sternum pain evaluation, symptoms, treatment, and prognosis. Understand the importance of accurate medical coding and thorough documentation in healthcare settings for proper diagnosis and reimbursement.
Also known as
Chondrosternal pain
Pain localized to the chondrosternal joint.
Chest pain, unspecified
Pain in the chest area, not otherwise specified.
Pain in unspecified joint
Pain in a joint, but the specific joint is not documented.
Pain, not elsewhere classified
General pain that cannot be categorized elsewhere.
Follow this step-by-step guide to choose the correct ICD-10 code.
Is the sternum pain traumatic in origin?
Yes
Fracture confirmed?
No
Tietze Syndrome confirmed?
When to use each related code
| Description |
|---|
| Sternum pain |
| Costochondritis |
| Precordial catch syndrome |
Using unspecified ICD-10 codes like R07.89 (Chest pain, unspecified) when more specific diagnoses related to sternum pain are documented, impacting reimbursement and data accuracy.
Miscoding or undercoding costochondritis (M94.0), a common cause of sternum pain, can lead to incorrect DRG assignment and lost revenue.
Failing to distinguish between traumatic (S22) and non-traumatic sternum pain etiologies creates coding errors and affects injury severity reporting.
Q: What are the key differential diagnoses to consider when a patient presents with sternum pain radiating to the back and arm, and how can I effectively differentiate between them?
A: Sternum pain radiating to the back and arm can indicate several conditions requiring careful differentiation. While musculoskeletal causes like costochondritis or Tietze syndrome are common, more serious etiologies like angina pectoris, pericarditis, aortic dissection, and esophageal spasm must be ruled out. A thorough clinical evaluation, including a detailed history, physical exam focusing on cardiac and pulmonary systems, and targeted diagnostic tests (ECG, cardiac enzymes, chest X-ray, potentially CT angiography depending on suspicion) are essential to accurate diagnosis. Exploring how risk factors, pain characteristics (e.g., sharp, burning, squeezing), and associated symptoms (e.g., shortness of breath, nausea) can guide differential diagnosis is crucial. Consider implementing a standardized assessment pathway for chest pain to ensure timely and appropriate management. Learn more about the red flags for serious cardiovascular conditions in patients presenting with chest pain.
Q: When should I suspect cardiac causes for sternum pain and what immediate management steps are crucial in a primary care setting?
A: Suspecting a cardiac cause for sternum pain is paramount, particularly when the pain is described as pressure, tightness, squeezing, or heaviness, radiating to the left arm, jaw, or back, and accompanied by diaphoresis, nausea, or shortness of breath. In a primary care setting, immediate management includes obtaining a 12-lead ECG, assessing vital signs (heart rate, blood pressure, oxygen saturation), administering aspirin (if not contraindicated), and ensuring supplemental oxygen. If the ECG shows ST-segment elevation or other concerning changes suggestive of acute myocardial infarction, prompt activation of the emergency medical system for transfer to a cardiac catheterization lab is critical. Consider implementing a chest pain protocol in your clinic to streamline assessment and management. Explore how to recognize atypical presentations of acute coronary syndrome, particularly in women and older adults.
Patient presents with complaints of sternum pain, also described as chest pain localized to the breastbone area. Onset of pain is described as (acute, subacute, chronic), and the character of the pain is reported as (sharp, dull, aching, burning, pressure, tightness). Patient denies (or reports) any associated symptoms such as shortness of breath, dyspnea on exertion, radiating pain to the arm, jaw, or back, diaphoresis, nausea, or lightheadedness. The patient reports (or denies) any recent trauma, injury, or strenuous activity involving the chest wall. Medical history includes (list relevant medical conditions such as costochondritis, GERD, angina, anxiety, etc.). Physical examination reveals (tenderness to palpation, crepitus, swelling, or normal findings) over the sternum. Cardiovascular exam including heart rate, rhythm, and auscultation is (normal or abnormal, specifying findings). Pulmonary examination including lung sounds is (normal or abnormal, specifying findings). Differential diagnosis includes costochondritis, Tietze syndrome, sternal fracture, angina pectoris, musculoskeletal pain, and gastroesophageal reflux disease. Initial treatment plan includes (conservative management such as rest, ice, NSAIDs, or further investigations such as ECG, chest x-ray, cardiac enzymes, etc.). Patient education provided regarding (pain management, activity modification, and potential causes of sternum pain). Follow-up appointment scheduled for (date) to reassess symptoms and adjust treatment plan as needed. ICD-10 code considerations include (M96.60, M96.61, M96.62 based on specific location of pain and other relevant codes based on differential diagnosis and associated conditions). Medical billing codes will be determined based on the evaluation and management services provided and any procedures performed.