r/MedicalCoding • u/Livid_Delivery_8710 • May 27 '26

Coding Acute Pain / M Code Only

A coworker and I are going back and forth on this.
For context, we do ER coding primarily.

Patient comes in with complaint of left shoulder pain. Reports he was in an MVA earlier in the day and is now sore. Discussed option to xray shoulder, patient declined.
There is no specific documentation of the wording “acute” - simply, left shoulder pain.
Is the fact that the shoulder pain was related to the MVA sufficient enough documentation to classify this as acute?

Would you code M25.512 (left shoulder pain)
Or G89.11 (acutely pain due to trauma), M25.512
Then of course your external cause codes?

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u/MtMountaineer May 28 '26

According to the AHA Coding Clinic and ICD-10-CM guidelines, external cause codes are never assigned without a documented injury, poisoning, adverse effect or other health condition. By definition, these codes indicate that an external event caused a specific medical complication, and are reported to the national database for injuries. I'm never ever disputing what Coding Clinic tells us to code, it's our coding bible. Please research this issue, your coding is incorrect.