Question: Which ICD-9 codes should I use for disc protrusion midline at C 4/5 and C 3/4 and also for left buttock pain?
Answer: The ICD-9 code for disk protrusion of the cervical spine would be 722.0 (Intervertebral disc disorders; displacement of cervical intervertebral disc without myelopathy). The ICD-9 manual does not have a specific code for \pain, buttock,\" so coders have various opinions on what is appropriate. Several possibilities include low back pain (724.2, Lumbago), hip joint pain (719.45, Pain in joint; pelvic region and thigh), muscle pain (729.1, Myalgia and myositis, unspecified) or sacroiliac pain (724.6, Other and unspecified disorders of back; disorders of sacrum). Of this group, many coders believe 724.2 is the closest code to buttock pain.
You might also want to consider some disc- or spinerelated diagnoses if the patient has disc disease. The buttock pain could refer to sciatica, which is pain in the region secondary to lumbar disc disease (722.10, Lumbar intervertebral disc without myelopathy). Coccydynia (724.79, Disorders of coccyx; other) can also present as buttock pain. With so many possibilities, your best bet is to talk with the physician to see if he or she can make a more specific diagnosis that you can accurately code.