M54.2
Cervicalgia
Cervicalgia, commonly referred to as neck pain, is a clinical condition characterized by pain localized to the cervical spine area. It does not include pain that radiates into the upper limbs (radiculopathy). The condition typically involves the muscles, ligaments, and joints of the neck. It is a highly prevalent musculoskeletal disorder that can be caused by degenerative changes, mechanical stress, or acute injury. Accurate diagnosis requires excluding neurological involvement or underlying systemic diseases. Management often involves a combination of physical therapy, pharmacological intervention, and ergonomic adjustments.
Clinical Symptoms
- Localized pain in the neck
- Neck stiffness and reduced range of motion
- Muscle spasms in the paracervical or trapezius muscles
- Tenderness upon palpation of the cervical spine
- Cervicogenic headaches starting at the base of the skull
Common Causes
- Poor posture and ergonomic strain
- Cervical spondylosis (degenerative changes)
- Muscle strain or ligamentous sprain
- Whiplash or minor trauma
- Stress-induced muscle tension
- Intervertebral disc degeneration without radiculopathy
Documentation & Coding Tips
Differentiate from Radiculopathy
Example: If the patient experiences radiating pain, numbness, or tingling into the arms, code M54.12 (Radiculopathy, cervical region) instead of M54.2.
Specify Chronicity
Example: Document if the pain is acute, subacute, or chronic, as this impacts the medical necessity of certain physical therapy modalities.
Exclude underlying Disc Disorders
Example: If the cervicalgia is a symptom of a specific cervical disc displacement or degeneration, code the M50 series as the primary diagnosis.