How to Read Your Medical Records After a Car Accident

Your medical records are the foundation of your insurance claim. They document the link between the accident and your injuries, the severity of those injuries, and the treatment required. Insurance adjusters review your records carefully — and they know exactly what to look for to reduce your settlement.

Understanding your own records puts you on equal footing. This guide explains the key terms, codes, and sections you'll encounter — and how adjusters typically interpret them. For context on the full range of adjuster tactics, see our separate guide.

Why Your Medical Records Matter for Your Claim

In an insurance claim, your medical records serve several functions:

• Establish causation: They document that your injuries were caused by the accident, not a pre-existing condition
• Quantify damages: Treatment costs and projected future care form the basis for economic damages
• Support pain and suffering: The documented nature and severity of injuries supports non-economic damage calculations
• Counter adjuster arguments: Detailed records make it harder to dismiss injuries as minor or pre-existing

Understanding ICD-10 Codes

The International Classification of Diseases, 10th Revision (ICD-10) is the standard system doctors use to code diagnoses. Every diagnosis in your medical records will have an ICD-10 code. Here are the most common ones in accident injury claims:

S Codes — Injury Codes (Most Important)

Code Range	Body Area	Plain Language
S10–S19	Neck	Injuries to the neck area, including cervical spine (whiplash)
S20–S29	Chest	Injuries to the thorax, including rib fractures
S30–S39	Abdomen/lower back	Injuries to the abdomen and lumbar region
S40–S49	Shoulder/upper arm	Shoulder joint and upper arm injuries
S50–S59	Elbow/forearm	Elbow and forearm injuries
S60–S69	Wrist/hand	Wrist and hand injuries
S70–S79	Hip/thigh	Hip and upper leg injuries
S80–S89	Knee/lower leg	Knee and lower leg injuries
S90–S99	Ankle/foot	Ankle and foot injuries

M Codes — Musculoskeletal Conditions

M codes refer to musculoskeletal and connective tissue conditions. They often indicate pre-existing or degenerative conditions, which is why adjusters pay close attention to them.

Code	Term	Plain Language
M47	Spondylosis	Degenerative change in the spine — common with age
M51	Thoracic, thoracolumbar, lumbosacral disc disorders	Disc problems in the mid/lower back
M54.2	Cervicalgia	Neck pain
M54.5	Low back pain	Pain in the lower back
M75	Shoulder lesions	Shoulder problems including rotator cuff issues
M79.3	Panniculitis	Inflammation of fatty tissue under the skin

Key Terms in Medical Records

Cervical Strain / Whiplash (S13.4)

Strain of the neck muscles and ligaments from the rapid back-and-forth motion in a collision. One of the most common accident injuries. Adjusters frequently try to minimize this as "just a sprain" despite the fact that it can cause lasting pain and neurological symptoms.

Herniated Disc (M51.1)

A spinal disc that has ruptured or bulged out of position, potentially pressing on nerves. Can cause radiating pain, numbness, or weakness. Adjusters often claim this is degenerative/pre-existing if the patient is over 35.

Radiculopathy (M54.1)

Pinched nerve pain that radiates from the spine into the arms or legs ("pinched nerve"). Common with cervical or lumbar disc injuries. Significantly impacts daily functioning and supports higher pain and suffering claims.

Contusion

A bruise — damage to tissue without breaking the skin. Contusions can involve internal organs or deep tissue even without visible external bruising.

Diagnosis vs. Impression vs. Assessment

These terms are sometimes used interchangeably in records. "Impression" and "assessment" typically mean the doctor's working diagnosis at that visit. A confirmed "diagnosis" is usually established after imaging results or specialist evaluation.

Prognosis

The expected future course of the condition. A poor prognosis (chronic pain, permanent limitation) significantly increases the value of a claim. Ask your doctor to include a written prognosis in your records.

What Adjusters Look for in Your Records

When an adjuster reviews your medical records, they are specifically looking for:

• Gaps in treatment — did you miss appointments or stop treatment? This suggests recovery or non-serious injury.
• Pre-existing M codes — anything that suggests a prior condition they can blame.
• Inconsistencies — if you told the ER doctor "mild neck pain" but later claimed severe injury, they'll use that discrepancy.
• Lack of specialist documentation — relying only on a general practitioner's notes may understate your injuries.
• No objective findings — if your records say "patient reports pain" without MRI/X-ray confirmation, adjusters treat the claim as weaker.

How to Strengthen Your Medical Records

• Be thorough with your doctor. Describe every symptom, no matter how minor it seems. If it's not in the record, it doesn't exist for claims purposes.
• Describe functional limitations. Tell your doctor what you can't do: "I can no longer lift my arm above shoulder height," "I cannot sit for more than 20 minutes." These functional descriptions support both medical treatment and pain and suffering claims.
• Request objective testing. MRI, X-ray, nerve conduction studies, and similar tests create objective documentation that's much harder for adjusters to dispute.
• Don't exaggerate — but don't minimize. Accurate documentation is what protects you. Don't say "I'm doing better" if you're not.
• Request a written prognosis. Ask your doctor to document in writing what ongoing treatment you'll need and any permanent limitations.