In this topic will discuss on ICD 10 code for Myalgia and its coding guidelines along with examples.
Myalgia means pain in one or multiple muscles. Pain can occur in a localized area only for few muscles or throughout the whole body. Sometimes pain happens only for a short period of time and some other time pain lasts for months or years. Myalgia is not a disease instead symptom of another problem. Reasons for muscle pain may be stress, minor injury, overuse, side effect of medication, infection or inflammation or any other disease.
Muscle pain is one of the main symptoms in patients with COVID-19.
Below are few common causes of myalgia:
- Lyme disease
- Rheumatoid arthritis
- Polymyalgia Rheumatica
There may be fever and chills associated with muscle pain if the pain is due to an infection. Severe pain can cause fatigue and interrupt normal daily activities and that may lead to depression.
Tests and Diagnosis:
Physician may need to do condition specific tests apart from checking history and physical examination as myalgia is a symptom of another disease. Different types of blood tests, radiology tests (X-Ray, MRI, CT), nerve conduction studies etc are used to find out the underlying condition.
ICD 10 Code for Myalgia and guidelines:
ICD 10 Code for Myalgia for localized and systemic muscle pain is found in chapter 13 of ICD-10 CM manual – diseases of musculoskeletal system and connective tissue, code range M00 – M99
|ICD 10 Codes for Myalgia||ICD 10 Codes for Myalgia – Description|
|M79.10||Myalgia unspecified site|
|M79.11||Myalgia of mastication muscle|
|M79.12||Myalgia of head, neck, auxiliary muscle|
|M79.18||Myalgia other specified site|
- Myalgia traumatic should be coded to “other injury of unspecified body region” Dx T14.8XXA, T14.8XXD or T14.8XXS
- Epidemic cervical myalgia, epidemic pleurodynia and epidemic myalgia should be coded to ICD B33.0 as per ICD-10 CM manual.
- Fibromyalgia – It is not an inflammatory disease instead a chronic pain syndrome causes muscle pain, tenderness, fatigue and difficulty sleeping. ICD-10 CM manual index leads to Dx M79.7
- Polymyalgia – This leads to ICD M35.3 which is an inflammatory disease of muscle (Polymyalgia Rheumatica).
- Do not code Dx R07 (pain in throat and chest) category when coding B33.0 as it is in excludes 1 list.
- Keep in mind that myalgia is a symptom, hence follow ICD coding guideline of not coding signs and symptoms when there is a definitive diagnosis.
Below are few examples on coding Myalgia.
ICD 10 Codes for Myalgia Example 1:
58 year old Christina has come to clinic with muscle pain and extreme tiredness from past one week. She use heat compressor and over the counter pain medications to relieve the pain. Her medical history includes hypertension and diabetes with current medication use of lisinopril and metformin. She is alert and oriented obese woman with BMI of 37. Vitals found slower heart rate and BP of 110/75 mmHg. Skin exam showed dryness. Musculoskeletal exam showed muscle pain and leg swelling. Blood lab tests were performed and the case was diagnosed as hypothyroidism.
E03.9 – Hypothyroidism
E11.9 – DM
I10 – HTN
E66.9 – Obesity
Z68.37 – BMI
Note: Myalgia is not coded in this scenario as the patient comes in with a symptom of myalgia and this was diagnosed as hypothyroidism.
ICD 10 Codes for Myalgia Example 2:
Augustine is a 62 year old male with past medical history of rheumatoid arthritis and diabetes. He is doing a tele visit today through doxy.me for muscle pain and joint pain. He has run out of RA medication methotrexate from past 1 week. His muscle and joint pains have increased from that time. He has not visited doctor due to COVID-19 pandemic. His granddaughter has helped him to make this televisit appointment and connect to doctor. He is on insulin for diabetes. He states that his hand joints become stiff some days in the early morning. Examination finding include skin dryness and swollen joints. Prescription is given for pain medication, pain balm and methotrexate.
M79.10 – Myalgia
M06.9 – RA
E11.9 – DM
Z79.4 – Insulin use
Note: In this scenario myalgia is chronic as a part of already existing rheumatoid arthritis.