According to healthcare reports, neck pain affects around 70% of people in one way or the other. Currently, the prolonged poor posture due to the excessive usage of tech devices like smartphones, tablets, laptops etc., is responsible for neck pain also known as text neck. Clinical studies tell us that 3,551 out of 100,000 people suffer from cervical discomfort.

What Is Text Neck?

Commonly known as tech neck, this condition points towards repetitive stress on the soft tissues present in the neck, upper back, and spine. People experience it due to continuous hunched or bent necks often seen and experienced while using handheld devices and laptops.

According to healthcare experts, the arched position of the upper body for an extended period is responsible for the tech neck. The most affected areas in the human body are the neck, the upper back, and the shoulder. In severe cases, patients even complain about muscle strains and pain in the mid back.

Correct use of M54.2: ICD-10 code for Neck Pain

The correct ICD-10 code to report neck pain, text neck, or tech neck is M54.2. Healthcare providers ensure they’re precise in their usage of this billable code to achieve correct documentation. Known  cervical radiculopathy in the medical world, its diagnosis includes nerve pain due to compression of nerves in the cervical spine.

Included in the chapter on the musculoskeletal system and connective tissue, M54.2 falls in the M54 category of Dorsalgia. Its usage in the documentation clearly specifies that the pain is affecting the patient in the cervical/neck area of the spine.

Typically, the pain caused due to compression of nerves in the neck radiates into the upper back, shoulders, and even arms and hands. The person suffering from it may also experience numbness or weakness in these body parts.

Neck Pain Code: Transition from ICD-9 to ICD-10

With the transition from ICD-9-CM to ICD-10-CM systems of medical classification, the shift has impacted neck pain diagnosis and documentation. While in ICD-9, neck pain was coded using 723.1. Although it did provide a clear overview of the condition faced by the patient, however, it didn’t serve well in capturing nuanced variations.

Since the tenth edition of the International Classification of Diseases has taken over, we’ve noticed that tech neck coding has become comprehensive and specific. This expansion in its scope allows medical specialists to signal towards many aspects of neck pain in a more clarified and precise way.

They can classify different aspects related to text pain, like location, severity, and underlying issues, for better diagnosis and enhanced treatment, resulting in quality patient care.

Using ICD-10 Code for Tech Pain/Neck Pain

In the clinical terminology, neck pain is called Cervicalgia and after October 1, 2024, with the introduction of ICD-10, the correct way to document this ailment in the coded form is via M54.2. The new code acts as a clear communicator between different entities regarding this troublesome condition, affecting many in modern times.

It helps healthcare professionals, insurance entities, 3rd party medical billing companies, and others involved to better understand the intricacies and streamline administrative processes.

Symptoms Commonly Associated with M54.2

As reported by patients, neck pain, referred to as Cervical Radiculopathy in the medical industry, has the following common symptoms

  • Pain in the neck that may even radiate to arms, hands, and even fingers
  • Numbness or tingling sensation in the arms or hands
  • Headache resulting from muscle tightness in the neck
  • Limited range of motions, especially when turning the head
  • Muscle tightness or spasms in the neck or even back
  • Weakness in shoulders or arm muscles
  • Consistent stiffness in the neck and upper back region

Common Reasons for Neck Pain

Neck pain caused by looking down at electronic devices for an extended period of time is also known as tech pain or text pain. It is one of the most common ailments troubling young people and those using smartphones or working on laptops.

Apart from these, there are multiple other reasons behind neck pain that can range from muscle strains to complicated degenerated conditions. Some common reasons for neck pain are as follows.

Muscle Strain

This is the foremost reason why millions of patients complain about neck pain. It could be due to extreme strain on neck muscles. This strain could be due to hours of sitting in the same position, heavy weight lifting, repetitive motions, or muscle fatigue.

Bad Posture

Poor posture, such as a hunched position due to excessive usage of smartphones, especially among youngsters, results in extra pressure on the ligaments and neck muscles. Just like muscle strain, it also leads to discomfort and, if not treated timely, could lead to pain.

Sudden Jerk

A jolt, jerk, or a lurch of the head or neck resulting often from car accidents, falling down or sports injuries may result in damaging soft tissues of the neck. The person experiencing it could end up with pain and stiffness.

Strain

Trauma or sudden uncontrolled movements cause strain in the sensitive neck muscles. Sudden twists, lifting heavy weights, or an accident limits the range of motions and is considered one of the main reasons for neck pain.

Wear and Tear

Some patients suffer from degenerative changes in discs in the neck. It could be the reason for less elasticity, lowered disc height, increased friction between vertebrae, resulting in pain and stiffness.

Disc Herniation

Some patients suffer from herniated discs in the cervical spine and compression of nerves in the nearby areas. This bulging or disc herniation is the cause of numbness, pain radiating to shoulders, arms, and upper back, and muscle weakness in the neck and surrounding body parts.

New Documentation Requirements

We see strict documentation standards regarding M54.2 and its related codes in the latest update of the International Classification of Diseases. Going forward, healthcare providers and medical billers employed by medical billing services companies must be very careful about detailed documentation before assigning any code. Proper documentation and coding for neck pain are essential for pain management billing services to ensure accurate reimbursements and streamline the revenue cycle.

Documentation requirements for M54.2 are as follows:

  • A record of clinical symptoms with comprehensive details
  • Findings to support diagnosis of Cervicalgia
  • Full documentation of pain severity and precise anatomical location
  • Patient history and all supporting material that may affect the treatment approach

Moreover, healthcare specialists must abolish terms that signify uncertainty in the documentation. These terms include ‘probable’, suspected, ‘questionable’ or, ‘rule out’. They must ensure clarity by integrating codes that show certainty for every encounter. This should be done by using symptom codes when the definite diagnosis remains unclear.

Examination Findings That Back M54.2 Diagnosis

An in-depth physical examination supports the neck pain diagnosis. This is why the documentation must contain the following:

Assessment for Range of Motion: If the healthcare provider feels any limited range of motion, they must note the constrained range of motion or restrictions.

Palpation Findings: During the cervical examination, note down any ‘palpable muscle spasm’ or any tenderness on and around the neck.

Musculoskeletal Examination: Check for any deformities in neck alignment and supporting muscles to establish a clinical diagnosis.

Neurological Screening: The numbness or tingling sensation in the shoulders, arms, and hands must also be mentioned – if any. Reflex testing and muscle strength must also be checked to know if there’s any probability of radiculopathy.

According to Eeric Truumees, a board-certified, fellowship-trained orthopedic surgeon specializing in spinal trauma and complex/revision spine surgery, vertebral endplates could be the reason for chronic low back pain instead of chronic neck pain. This difference helps distinguish between neck pain and other related issues.

Distinguishing Between Billable ICD-10 Codes for Neck Pain

Healthcare providers must know the difference between billable and non-billable codes. The same goes for Cervicalgia or neck pain. Appending the correct ICD-10 codes for tech pain demands precision and leads to complete and timely reimbursements against services delivered.

This is why it is imperative for healthcare providers to be careful and specific when using appropriate codes. It not only streamlines the payment process but also optimizes administrative processes.

Main Billable ICD-10 Codes for Tech Pain M54.2

M54.2: ICD-10 code for Cervicalgia, which is a term for neck pain.

M50.1: Cervical disc disorder with radiculopathy. It covers disc issues involving nerve entrapment.

M50.2: Another cervical disc displacement when one or more of the intervertebral discs in the cervical spine are damaged.

G54.2: Code for Cervical root disorders, not elsewhere classified.

S13.4: Sprain of ligaments of the cervical spine.

M53.1: Cervicobrachial Syndrome. Stands for diffuse neck and arm discomfort.

Using these specific billable codes correctly means you get complete payments against services provided to individuals complaining about neck pain. Flawless documentation and claim creation using billable ICD-10 codes promise RCM streamlining for your practice and help secure the right income.

Clinical Symptoms to Be Recorded

During the phase of documenting clinical symptoms for Cervicalgia, it is imperative for healthcare providers that their in-house staff or 3rd party medical billers include the below-mentioned elements.

Pain Characteristics

While documentation, it is essential to mention if the pain of unwanted sensation feels as dull, constant, or acute pain. Also, does it remain persistent or make a comeback every now and then?

Stiffness in The Area

Note down the condition if the patient is facing mobility constraints, stiffness or going through constant patterns.

Muscle Spasms

Write about any involuntary contractions of the neck muscles if the patient complains about it.

Radiation Patterns

Mention if the pain, starting from the neck, radiates to other connected parts like shoulders, upper back and, arms, etc.

Related Symptoms

Ask the patient about headaches and note if they’re facing headaches above the neck or numbness in the region.

Symptom Duration

Classify the pain between acute – there for days or weeks – or chronic – that is constantly bothering the patient for months or even more. This point has a direct effect on the specific type of treatment.

How to Document Pain Severity and Location for M54.2?

Documenting the exact type of pain sets the tone for proper coding for neck pain medically classified by M54.2. The documentation must be based on the following:

Pain severity is measured using a scale ranging from 0-10. This standardized scale quantifies the person’s subjective experience. The healthcare provider must also clearly mention about the exact area of pain, type, intensity, and whether it is acute or chronic via the patient’s description of their condition.

 

Be specific about where the pain is. Mention if it’s on the left side, both sides, or in a certain area of the neck. Don’t forget to include if the pain spreads to the shoulders or arms.

2025 Update Affecting Reimbursement Against Neck Pain Services

The 2025 update has changed the nuances of neck pain treatment significantly. Based on the new financial landscape, the treatment providers have changed the way they bill against M54.2 and collect reimbursements for Cervicalgia.

This mandates that healthcare providers, their in-house staff, medical billers, and coders working in medical billing companies are up to date with these changes. They must stay current to ensure flawless claim creation and submission, maintaining practice credibility and collecting the right amount of revenue against services rendered.

Payment Changes to Expect Against M54.2 In 2025

The 2025 Physician Fee Schedule establishes a conversion factor of 32.3465, introducing a 0.02 percent positive budget neutrality adjustment. This minimal increase fails to offset the elimination of the temporary 2.93 percent payment enhancement that expired on December 31, 2024. Practices billing M54.2 face essentially flat reimbursement rates compared to previous fiscal periods.

Outpatient service facilities will experience a 2.9% payment update, calculated from the projected hospital market basket percentage increase of 3.4% minus a 0.5 percentage point productivity adjustment. This adjustment directly impacts neck pain treatment reimbursement across various clinical settings.