ICD-10 Coding for Bilateral Sciatica(M54.31, M54.32)
Complete ICD-10-CM coding and documentation guide for Bilateral Sciatica. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Bilateral Sciatica
M54.3-M54.32Primary Range
Dorsalgia, including sciatica
This range includes codes for sciatica, specifying laterality for accurate diagnosis and treatment.
Intervertebral disc disorders with radiculopathy
Used when sciatica is due to disc disorders, providing specificity for underlying causes.
Code Comparison: When to Use Each Code
Compare key differences between these codes to ensure accurate selection
| Code | Description | When to Use | Key Documentation |
|---|---|---|---|
| M54.31 | Sciatica, right side | Use when sciatica symptoms are present on the right side. |
|
| M54.32 | Sciatica, left side | Use when sciatica symptoms are present on the left side. |
|
Clinical Decision Support
Always review the patient's clinical documentation thoroughly. When in doubt, choose the more specific code and ensure documentation supports it.
Key Information: How do you code bilateral sciatica in ICD-10?
Essential facts and insights about Bilateral Sciatica
Primary ICD-10-CM Codes for bilateral sciatica
Decision Criteria
clinical Criteria
- Presence of right leg pain with neurological deficits
Applicable To
- Right-sided sciatica
Excludes
- Sciatic nerve lesion (G57.0)
Clinical Validation Requirements
- Pain radiating down the right leg
- Positive straight leg raise test on the right
Code-Specific Risks
- Incorrect laterality documentation
Coding Notes
- Ensure laterality is documented accurately to avoid unspecified coding.
M54.32 - Sciatica, left side
Use when sciatica symptoms are present on the left side.
Applicable To
- Left-sided sciatica
Excludes
- Sciatic nerve lesion (G57.0)
Clinical Validation Requirements
- Pain radiating down the left leg
- Positive straight leg raise test on the left
Coding Notes
Ensure laterality is documented accurately to avoid unspecified coding.
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 Sciatica to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code M54.31.
Impact
Clinical: May lead to inappropriate treatment., Regulatory: Non-compliance with coding guidelines., Financial: Potential for claim denials.
Mitigation Strategy
Always specify right, left, or bilateral in documentation.
Impact
Reimbursement: May lead to claim denials or reduced reimbursement., Compliance: Non-compliance with specificity requirements., Data Quality: Decreases accuracy of clinical data.
Mitigation Strategy
Document and code each side separately using M54.31 and M54.32.
Impact
Using M54.3 instead of specific laterality codes.
Mitigation Strategy
Ensure documentation specifies laterality for accurate coding.
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 Sciatica, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Bilateral Sciatica
Use these documentation templates to ensure complete and accurate documentation for Bilateral Sciatica. These templates include all required elements for proper coding and billing.
Bilateral sciatica due to disc herniation
Specialty: NeurologyRequired Elements
- Pain location and severity
- Neurological deficits
- Imaging results
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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