ICD-10 Coding for Degenerative Intervertebral Disc Disease(M51.360, M51.362)
Complete ICD-10-CM coding and documentation guide for Degenerative Intervertebral Disc Disease. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Degenerative Intervertebral Disc Disease
M51.3-M51.37Primary Range
Other intervertebral disc degeneration
This range includes codes specific to degenerative changes in the intervertebral discs, particularly in the lumbar and lumbosacral regions.
Code Comparison: When to Use Each Code
Compare key differences between these codes to ensure accurate selection
| Code | Description | When to Use | Key Documentation |
|---|---|---|---|
| M51.360 | Other intervertebral disc degeneration, lumbar region with axial back pain | Use when the patient presents with lumbar disc degeneration and axial back pain without radiation. |
|
| M51.362 | Other intervertebral disc degeneration, lumbar region with back and leg pain | Use when lumbar disc degeneration causes both back and leg pain. |
|
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: ICD-10 code for degenerative intervertebral disc disease
Essential facts and insights about Degenerative Intervertebral Disc Disease
Primary ICD-10-CM Codes for degenerative intervertebral disc disease
Decision Criteria
clinical Criteria
- MRI shows ≥30% loss of disc height and Modic changes.
Applicable To
- Discogenic low back pain without radiation
Excludes
- Spondylosis without myelopathy or radiculopathy (M47.816)
Clinical Validation Requirements
- MRI showing Modic changes
- ≥30% loss of disc height
Code-Specific Risks
- Ensure documentation specifies axial pain without radiation to avoid misclassification.
Coding Notes
- Ensure imaging findings support the diagnosis of disc degeneration.
M51.362 - Other intervertebral disc degeneration, lumbar region with back and leg pain
Use when lumbar disc degeneration causes both back and leg pain.
Applicable To
- Referred sclerotomal pain to lower extremity
Excludes
- Sciatica (M54.3)
Clinical Validation Requirements
- Positive discography
- Pain radiates to posterior thigh
Coding Notes
Ensure documentation differentiates between radicular and sclerotomal pain.
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 Degenerative Intervertebral Disc Disease to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code M51.360.
Impact
Clinical: Leads to misdiagnosis or inappropriate treatment., Regulatory: Non-compliance with documentation standards., Financial: Potential claim denials due to insufficient documentation.
Mitigation Strategy
Use specific terms like 'discogenic pain' and 'sclerotomal pattern'., Ensure detailed symptom and imaging documentation.
Impact
Reimbursement: Incorrect coding may lead to claim denials., Compliance: Non-compliance with updated coding standards., Data Quality: Inaccurate data collection affecting patient records.
Mitigation Strategy
Ensure use of updated 6-character codes specifying pain types.
Impact
Using outdated codes or incorrect pain specification can trigger audits.
Mitigation Strategy
Regularly update coding practices and verify code accuracy.
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 Degenerative Intervertebral Disc Disease, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Degenerative Intervertebral Disc Disease
Use these documentation templates to ensure complete and accurate documentation for Degenerative Intervertebral Disc Disease. These templates include all required elements for proper coding and billing.
Neurosurgery progress note for DDD
Specialty: NeurosurgeryRequired Elements
- Subjective symptoms
- Objective findings
- Assessment
- Plan
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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