ICD-10 Coding for Lumbosacral Degenerative Disc Disease(M51.360, M51.361, M51.362)
Complete ICD-10-CM coding and documentation guide for Lumbosacral Degenerative Disc Disease. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Lumbosacral Degenerative Disc Disease
M51.3-M51.37Primary Range
Other intervertebral disc degeneration
This range includes specific codes for lumbar and lumbosacral degenerative disc disease with varying pain presentations.
Low back pain and vertebrogenic pain
These codes are used for documenting pain associated with or differentiated from degenerative disc disease.
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 | Lumbar DDD with axial back pain only | Use when lumbar DDD is confirmed with axial back pain only. |
|
| M51.361 | Lumbar DDD with lower extremity pain only | Use when lumbar DDD is confirmed with lower extremity pain only. |
|
| M51.362 | Lumbar DDD with both back and leg pain | Use when lumbar DDD is confirmed with 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 lumbosacral degenerative disc disease
Essential facts and insights about Lumbosacral Degenerative Disc Disease
Primary ICD-10-CM Codes for lumbosacral degenerative disc disease
Decision Criteria
clinical Criteria
- MRI shows disc degeneration without radicular symptoms.
Applicable To
- Discogenic low back pain
Excludes
- Radiculopathy (M54.1-)
Clinical Validation Requirements
- MRI confirmation of disc degeneration
- Patient reports axial back pain
Code-Specific Risks
- Misclassification if radicular symptoms are present
Coding Notes
- Ensure documentation specifies 'discogenic' to differentiate from other causes of back pain.
M51.361 - Lumbar DDD with lower extremity pain only
Use when lumbar DDD is confirmed with lower extremity pain only.
Applicable To
- Referred leg pain without radicular features
Excludes
- Sciatica (M54.3-)
Clinical Validation Requirements
- Positive discography
- Lower extremity pain without radicular features
Coding Notes
Document non-radicular pain patterns clearly.
M51.362 - Lumbar DDD with both back and leg pain
Use when lumbar DDD is confirmed with both back and leg pain.
Applicable To
- Discogenic back pain with non-radicular lower extremity symptoms
Excludes
- Radiculopathy (M54.1-)
Clinical Validation Requirements
- MRI shows disc degeneration
- Patient reports both back and leg pain
Coding Notes
Ensure documentation specifies both back and leg pain without radicular features.
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 Lumbosacral Degenerative 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: May lead to inappropriate treatment plans., Regulatory: Non-compliance with documentation standards., Financial: Potential for claim denials or reduced reimbursement.
Mitigation Strategy
Always link pain to DDD if confirmed, Use specific ICD-10 codes
Impact
Reimbursement: Incorrect coding may lead to claim denials., Compliance: Non-compliance with ICD-10 coding guidelines., Data Quality: Inaccurate data reporting and analysis.
Mitigation Strategy
Add Excludes1 note: 'Low back pain due to DDD → Code M51.36- first'
Impact
High denial risk when using unspecified M51.36/M51.37 codes.
Mitigation Strategy
Ensure documentation specifies pain location and characteristics.
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 Lumbosacral Degenerative Disc Disease, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Lumbosacral Degenerative Disc Disease
Use these documentation templates to ensure complete and accurate documentation for Lumbosacral Degenerative Disc Disease. These templates include all required elements for proper coding and billing.
Neurosurgery Progress Note (Post-Op)
Specialty: NeurosurgeryRequired Elements
- Subjective pain report
- Objective imaging findings
- Assessment and plan
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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