ICD-10 Coding for Bilateral Lower Extremity Radiculopathy(M54.16)
Complete ICD-10-CM coding and documentation guide for Bilateral Lower Extremity Radiculopathy. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Bilateral Lower Extremity Radiculopathy
M54.1-M54.16Primary Range
Radiculopathy codes for various regions
This range includes codes for radiculopathy affecting different spinal regions, with M54.16 specifically for lumbar radiculopathy.
Intervertebral disc disorders with radiculopathy
This range includes codes for disc disorders that may cause radiculopathy, relevant when disc degeneration is the underlying cause.
Spinal stenosis, lumbar region
Used when spinal stenosis is the underlying cause of radiculopathy.
Key Information: How to code bilateral lower extremity radiculopathy
Essential facts and insights about Bilateral Lower Extremity Radiculopathy
Primary ICD-10-CM Code for bilateral lower extremity radiculopathy
Decision Criteria
clinical Criteria
- Confirmed nerve root compression via imaging or EMG
documentation Criteria
- Detailed documentation of symptoms and diagnostic findings
Applicable To
- Lumbar radiculopathy
Excludes
- Sciatica (M54.3x)
Clinical Validation Requirements
- MRI showing nerve root compression
- EMG confirming nerve root involvement
- Physical exam findings such as reflex loss or muscle weakness
Code-Specific Risks
- Incorrectly coding as low back pain (M54.5) when radiculopathy is confirmed
Coding Notes
- Ensure documentation specifies bilateral involvement and nerve roots affected.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting Bilateral Lower Extremity Radiculopathy to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code M54.16.
Impact
Clinical: Leads to misdiagnosis or incorrect treatment., Regulatory: Non-compliance with documentation standards., Financial: Potential for claim denials.
Mitigation Strategy
Use specific language, Include diagnostic test results
Impact
Reimbursement: Incorrect coding can lead to denied claims., Compliance: Non-compliance with coding standards., Data Quality: Inaccurate clinical data reporting.
Mitigation Strategy
Use M54.16 for confirmed lumbar radiculopathy.
Impact
Inaccurate or incomplete documentation can lead to audit findings.
Mitigation Strategy
Ensure thorough documentation of clinical findings and diagnostic tests.
Documentation errors, coding pitfalls, and audit risks are interconnected aspects of medical coding and billing. Addressing all three areas helps ensure accurate coding, optimal reimbursement, and regulatory compliance.
Frequently Asked Questions
Common questions about ICD-10 coding for Bilateral Lower Extremity Radiculopathy, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Bilateral Lower Extremity Radiculopathy
Use these documentation templates to ensure complete and accurate documentation for Bilateral Lower Extremity Radiculopathy. These templates include all required elements for proper coding and billing.
Confirmed Bilateral Radiculopathy
Specialty: NeurologyRequired Elements
- Patient history
- Physical exam findings
- Imaging results
- Electrodiagnostic studies
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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