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ICD-10 Coding for Lumbosacral Pain(M54.16, M54.50, M51.36)

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

Also known as:

Lower Back PainLumbosacral Radiculopathy

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Related ICD-10 Code Ranges

Complete code families applicable to Lumbosacral Pain

M54.5-M54.59Primary Range

Low back pain codes

These codes cover various types of low back pain, including unspecified and specified conditions.

M51.36-M51.37

Discogenic pain codes effective 2024

These codes are used for discogenic pain, a specific type of low back pain related to disc degeneration.

G89.2-G89.29

Chronic pain codes

These codes are used for chronic pain management, often in conjunction with site-specific codes.

Code Comparison: When to Use Each Code

Compare key differences between these codes to ensure accurate selection

CodeDescriptionWhen to UseKey Documentation
M54.16Radiculopathy, lumbar regionUse when nerve root compression is confirmed via imaging and clinical findings.
  • EMG/NCS showing radiculopathy
  • MRI demonstrating nerve root compression
  • Dermatomal sensory map
M54.50Low back pain, unspecifiedUse for nonspecific pain without identifiable cause after initial workup.
  • Absence of specific findings or identifiable cause
M51.36Discogenic pain, lumbar regionUse for discogenic pain with documented imaging findings.
  • MRI showing disc degeneration
  • Clinical signs like midline pain and sitting intolerance

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 pain

Essential facts and insights about Lumbosacral Pain

The ICD-10 code for unspecified lumbosacral pain is M54.50. For specific conditions like radiculopathy, use M54.16.

Primary ICD-10-CM Codes for lumbosacral pain

M54.16
Radiculopathy, lumbar region
Billable Code

Decision Criteria

clinical Criteria

  • Presence of radicular pain with imaging confirmation

Applicable To

  • Lumbar radiculopathy

Excludes

Clinical Validation Requirements

  • EMG/NCS showing radiculopathy
  • MRI demonstrating nerve root compression
  • Dermatomal sensory map

Code-Specific Risks

  • Incorrectly coding as nonspecific low back pain

Coding Notes

  • Ensure documentation specifies radiculopathy with imaging confirmation.
View Full Code Details

Ancillary Codes

Additional codes that should be used in conjunction with the main diagnosis codes when applicable.

Chronic pain due to trauma

G89.21
Use for chronic pain management visits.

Differential Codes

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

Other intervertebral disc displacement, lumbar region

M51.27
Use when disc displacement is confirmed without radiculopathy.

Radiculopathy, lumbar region

M54.16
Use when radiculopathy is confirmed.

Documentation & Coding Risks

Avoid these common documentation and coding issues when documenting Lumbosacral Pain to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code M54.16.

Impact

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

Mitigation Strategy

Ensure detailed clinical findings are documented, Use imaging results to support diagnosis

Impact

Reimbursement: May lead to lower reimbursement rates., Compliance: Non-compliance with coding guidelines., Data Quality: Decreased accuracy in clinical data.

Mitigation Strategy

Ensure specific conditions are coded with appropriate codes like M54.16 or M51.36.

Impact

Frequent use of unspecified codes like M54.50 can trigger audits.

Mitigation Strategy

Ensure documentation supports the most specific code possible.

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

Documentation Templates for Lumbosacral Pain

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

Physical Therapy Evaluation

Specialty: Physical Therapy

Required Elements

  • Subjective pain description
  • Objective findings
  • Assessment and plan

Example Documentation

**Subjective**: "52yo M reports 6-month history of right lumbosacral pain (7/10 VAS) radiating to lateral calf, worsening with prolonged sitting. Denies bowel/bladder changes." **Objective**: - Positive right SLR at 30° - Lumbar flexion limited to 50% ROM - Weakness (4/5) in right ankle dorsiflexion **Assessment**: "Lumbar radiculopathy (M54.16) with L5 nerve root involvement, confirmed by MRI showing L4-L5 foraminal stenosis." **Plan**: "Initiating McKenzie protocol; avoid repeated flexion activities."

Examples: Poor vs. Good Documentation

Poor Documentation Example
Patient has low back pain.
Good Documentation Example
Chronic axial lumbosacral pain (8/10 VAS) radiating to posterior thigh, positive seated slump test, MRI shows L5-S1 disc bulge compressing S1 nerve root.
Explanation
The good example provides specific details about the pain, its location, severity, and supporting imaging findings.

Need help with ICD-10 coding for Lumbosacral Pain? Ask your questions below.

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