Neck pain is one of the most common reasons people visit doctors, chiropractors, and physical therapists. From a billing perspective, it’s also one of the trickiest because providers must correctly report both the diagnosis and the services provided.
- ICD-10 codes explain why the patient came in (diagnosis).
- CPT codes explain what was done to evaluate or treat that diagnosis (services and procedures).
If you get the CPT code wrong, claims are denied, reimbursements are delayed, and audits become a risk. This guide breaks down the most relevant CPT codes for neck pain, with explanations, examples, and documentation tips.
What CPT Codes Represent
CPT (Current Procedural Terminology) codes are maintained by the American Medical Association (AMA). Each 5-digit code describes a medical, surgical, or diagnostic service. For neck pain:
- They cover evaluation and management (E/M) visits.
- They cover physical therapy, rehab, and chiropractic care.
- They cover imaging and diagnostic tests.
- They cover pain management injections.
- They cover surgical interventions.
Correct coding requires linking each CPT service to an appropriate ICD-10 code (such as M54.2 for neck pain).
Evaluation and Management (E/M) Codes for Neck Pain
These are the most common codes billed when a patient first presents with neck pain.
- 99202–99205 (New patients, office visits):
Example: A patient comes in for the first time with sudden neck stiffness. The provider documents history, exam, and treatment plan. - 99212–99215 (Established patients, office visits):
Example: A returning patient reports worsening pain despite therapy. The provider adjusts medications and orders imaging. - 99221–99223 (Initial hospital care):
Used when neck pain leads to hospital admission. - 99231–99233 (Subsequent hospital care):
For follow-up during hospital stay.
Documentation Tip:
The level of service depends on time spent and complexity of medical decision-making. Always document both.
Physical Therapy and Rehabilitation CPT Codes
Neck pain is often managed through therapy. These codes are billed by PTs, chiropractors, and sometimes physicians:
- 97110 – Therapeutic exercises (e.g., range of motion, strengthening).
- 97112 – Neuromuscular re-education (e.g., posture correction, balance training).
- 97140 – Manual therapy techniques (e.g., joint mobilization, soft tissue massage).
- 97530 – Therapeutic activities (e.g., functional training like lifting or carrying).
- 97012 – Mechanical traction (common for cervical spine issues).
Example:
A patient with cervical spondylosis undergoes 20 minutes of manual therapy (97140) and 15 minutes of therapeutic exercise (97110). Both codes can be billed if properly documented with time spent.
Diagnostic Imaging Codes
When conservative care isn’t enough, imaging comes next. Common CPT codes include:
- 72040 – Cervical spine X-ray, 2 or 3 views.
- 72050 – Cervical spine X-ray, 4 or 5 views.
- 72052 – Cervical spine X-ray, 6 or more views.
- 72141 – MRI cervical spine, without contrast.
- 72146 – MRI cervical spine, with contrast.
- 72156 – MRI cervical spine, with and without contrast.
- 70490 – CT neck, without contrast.
Documentation Tip:
Radiology reports must match the CPT description (e.g., number of views taken). Billing 72050 when only 3 views are taken is a common audit trigger.
Pain Management and Injection Codes
Interventional procedures are common for chronic neck pain, radiculopathy, or disc herniation:
- 62321 – Injection, cervical epidural, single level.
- 62323 – Injection, cervical epidural, with imaging guidance.
- 64490 – Cervical facet joint injection, single level.
- 64491 – Additional level (add-on code).
- 20552 – Trigger point injections, neck and back muscles.
- 77003 – Fluoroscopic guidance for spinal injections.
Example:
A patient with cervical radiculopathy receives a cervical epidural injection with imaging. Bill 62323 + 77003.
Surgical Procedure Codes for Neck Pain
If conservative care fails, surgical interventions may be coded:
- 22551 – Anterior cervical discectomy and fusion (ACDF), single level.
- 22552 – Each additional cervical level (add-on).
- 63020 – Laminotomy for decompression, cervical.
- 63045 – Laminectomy for decompression, cervical.
- 22845 – Anterior instrumentation for cervical spine.
- 22853 – Interbody device insertion.
Documentation Tip:
Always document the approach (anterior vs posterior), number of levels, and whether instrumentation was used.
Modifiers Frequently Used with Neck Pain CPT Codes
- -25 – Significant, separately identifiable E/M service on the same day as a procedure.
- -59 – Distinct procedural service (used for therapy codes or injections).
- -50 – Bilateral procedure (rare in cervical spine but may apply).
- -26 – Professional component (e.g., radiology interpretation).
- -TC – Technical component (e.g., imaging performed by facility).
Best Practices for Billing Neck Pain CPT Codes
- Link ICD-10 and CPT codes – Example: M54.2 (Neck pain) + 97140 (Manual therapy).
- Track time accurately for therapy and E/M codes.
- Use add-on codes properly for multi-level procedures.
- Include imaging guidance codes when applicable (e.g., 77003 for injections).
- Stay updated annually – CPT codes change every year; outdated codes lead to denials.
Why Correct Coding Matters
- Financial impact: Incorrect coding leads to underpayment or recoupment.
- Compliance: Avoids fraud risk and payer audits.
- Continuity of care: Proper codes create accurate patient records.
- Claim approval speed: Clean claims mean faster reimbursements.
FAQs
Q1: What is the most commonly used CPT code for neck pain office visits?
For established patients, 99213 and 99214 are the most frequent.
Q2: Can E/M codes and therapy codes be billed together?
Yes, if both are medically necessary and documented separately. Modifier -25 may be required.
Q3: How do you code for multiple therapy modalities in one session?
Use distinct CPT codes with modifier -59 if needed, and document exact minutes spent on each.
Q4: Are imaging guidance codes always billable for injections?
Yes, if imaging (fluoro/CT/ultrasound) was used and documented. Otherwise, don’t bill them.
Q5: Can a chiropractor bill neck pain CPT codes?
Yes, chiropractors often use therapy (97140, 97110) and traction (97012) codes. But surgical codes are physician-only.
Final Thoughts
CPT coding for neck pain is about precision. Each service—whether an office visit, therapy, injection, or surgery—has a code that must align with documentation and diagnosis. Linking ICD-10 and CPT codes, applying modifiers correctly, and staying updated with yearly changes ensures clean claims and maximum reimbursement.
If you treat patients with neck pain, getting CPT coding right protects your revenue and your compliance.