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ICD-10 Coding for Lumbalgia(M54.5, M54.41, M51.16, S33.5XXA)

Complete ICD-10-CM coding and documentation guide for Lumbalgia. Includes clinical validation requirements, documentation requirements, and coding pitfalls.

Also known as:

Low Back PainLumbago

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Related ICD-10 Code Ranges

Complete code families applicable to Lumbalgia

M54.5-M54.59Primary Range

Low back pain and related conditions

This range covers non-specific low back pain and its variations, including lumbago with sciatica.

M51.1-M51.9

Intervertebral disc disorders

These codes are used when low back pain is associated with disc disorders, such as herniation or displacement.

S33.5XXA

Sprain and strain of lumbar spine

This code is used for acute traumatic lumbar sprains, often in cases of injury.

Code Comparison: When to Use Each Code

Compare key differences between these codes to ensure accurate selection

CodeDescriptionWhen to UseKey Documentation
M54.5Low back painUse for non-specific low back pain without specific etiology.
  • Pain localization without radiation or nerve findings
M54.41Lumbago with sciatica, right sideUse when sciatica is present with right-sided symptoms.
  • Radiation past knee with positive straight leg raise test
M51.16Intervertebral disc disorders with radiculopathy, lumbar regionUse when disc disorder is confirmed as the cause of symptoms.
  • MRI-confirmed herniation with neurological deficits
S33.5XXASprain and strain of lumbar spine, initial encounterUse for acute traumatic lumbar sprains.
  • Mechanism of injury and point tenderness

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 lumbalgia

Essential facts and insights about Lumbalgia

The ICD-10 code for lumbalgia is M54.5, used for non-specific low back pain.

Primary ICD-10-CM Codes for lumbalgia

M54.5
Low back pain
Non-billable Code

Decision Criteria

clinical Criteria

  • Pain localized to lumbar region without radiation.

Applicable To

  • Lumbago

Excludes

Clinical Validation Requirements

  • Pain localization without radiation or nerve findings

Code-Specific Risks

  • Risk of using when a more specific cause is documented.

Coding Notes

  • Ensure no specific cause like strain or disc disorder is documented.
View Full Code Details

Differential Codes

Alternative codes to consider when ruling out similar conditions to the primary diagnosis.

Lumbar disc disorder with radiculopathy

M51.16
Use when MRI confirms herniation with neurological deficits.

Lumbago with sciatica, left side

M54.42
Use for left-sided symptoms.

Lumbago with sciatica, right side

M54.41
Use when sciatica is primary symptom without confirmed disc disorder.

Low back pain

M54.5
Use when no specific injury is documented.

Documentation & Coding Risks

Avoid these common documentation and coding issues when documenting Lumbalgia to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code M54.5.

Impact

Clinical: Inaccurate treatment planning., Regulatory: Non-compliance with coding standards., Financial: Potential claim denials.

Mitigation Strategy

Always specify right or left side in documentation.

Impact

Reimbursement: Incorrect coding may lead to claim denials., Compliance: Non-compliance with coding guidelines., Data Quality: Inaccurate clinical data representation.

Mitigation Strategy

Use S33.5XXA for traumatic lumbar sprain.

Impact

Failure to document laterality in sciatica cases.

Mitigation Strategy

Implement mandatory laterality fields in EHR templates.

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 Lumbalgia, with expert answers to help guide accurate code selection and documentation.

Documentation Templates for Lumbalgia

Use these documentation templates to ensure complete and accurate documentation for Lumbalgia. These templates include all required elements for proper coding and billing.

Neurology Progress Note

Specialty: Neurology

Required Elements

  • Location of pain
  • Character of pain
  • Radiation details
  • Neurological correlation
  • Provocative tests
  • Imaging correlation

Example Documentation

Location: L4-L5, Character: aching, Radiation: to knee, Neurological Correlation: numbness in L5 dermatome, Provocative Tests: SLR 45°, Imaging Correlation: MRI Date: 01/01/2023

Examples: Poor vs. Good Documentation

Poor Documentation Example
LBP improved with exercises
Good Documentation Example
50% reduction in central lumbar pain at L4-L5 (4/10 VAS), persistent right L5 radicular symptoms unchanged, modified Oswestry score improved from 60% to 40%
Explanation
The good example provides specific pain reduction metrics and functional improvement scores.

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