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ICD-10 Coding for Sciatica Left Side(M54.32, M54.42, M51.16)

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

Also known as:

Left-Sided SciaticaLeft Sciatic Nerve Pain

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Related ICD-10 Code Ranges

Complete code families applicable to Sciatica Left Side

M54.3-M54.4Primary Range

Dorsalgia

This range includes codes for sciatica and lumbago with sciatica, specifying laterality.

M51.1

Intervertebral disc disorders with radiculopathy

This range includes codes for disc disorders causing radiculopathy, which can underlie sciatica.

Code Comparison: When to Use Each Code

Compare key differences between these codes to ensure accurate selection

CodeDescriptionWhen to UseKey Documentation
M54.32Sciatica, left sideUse when sciatica is isolated to the left side without accompanying low back pain.
  • Radiating pain to left leg
  • Positive left straight leg raise (SLR) test
  • MRI findings if applicable
M54.42Lumbago with sciatica, left sideUse when both low back pain and left-sided sciatica are present.
  • Low back pain with radiation to left leg
  • Positive left SLR test
M51.16Intervertebral disc disorders with radiculopathy, lumbar regionUse when sciatica is due to a confirmed herniated disc.
  • MRI-confirmed disc herniation
  • Nerve root compression

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 left-sided sciatica

Essential facts and insights about Sciatica Left Side

The ICD-10 code for left-sided sciatica is M54.32, used when sciatica is isolated to the left side without low back pain.

Primary ICD-10-CM Codes for sciatica left side

M54.32
Sciatica, left side
Billable Code

Decision Criteria

clinical Criteria

  • Patient reports radiating pain from lower back to left leg.

documentation Criteria

  • Documentation specifies 'left side' and absence of low back pain.

Applicable To

  • Left-sided sciatica without lumbago

Excludes

  • Lumbago with sciatica (M54.42)

Clinical Validation Requirements

  • Radiating pain to left leg
  • Positive left straight leg raise (SLR) test
  • MRI findings if applicable

Code-Specific Risks

  • Failing to document laterality
  • Not specifying absence of lumbago

Coding Notes

  • Ensure documentation specifies 'left side' and absence of lumbago.
View Full Code Details

Ancillary Codes

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

Lesion of sciatic nerve, unspecified

G57.00
Use if EMG confirms neuropathy without spinal cause.

Differential Codes

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

Lumbago with sciatica, left side

M54.42
Presence of low back pain with left leg radiation.

Sciatica, left side

M54.32
Absence of low back pain.

Documentation & Coding Risks

Avoid these common documentation and coding issues when documenting Sciatica Left Side to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code M54.32.

Impact

Clinical: Inadequate clinical validation of diagnosis., Regulatory: Non-compliance with coding guidelines., Financial: Potential claim denials or audits.

Mitigation Strategy

Ensure all relevant tests are documented., Include test results in patient records.

Impact

Reimbursement: Incorrect coding may lead to denied claims., Compliance: Non-compliance with ICD-10 specificity requirements., Data Quality: Inaccurate patient records and data reporting.

Mitigation Strategy

Ensure documentation specifies 'left side' for sciatica.

Impact

Reimbursement: Potential underpayment if lumbago is not coded., Compliance: Failure to meet coding guidelines for specificity., Data Quality: Misrepresentation of patient condition.

Mitigation Strategy

Use M54.42 when low back pain is present with sciatica.

Impact

Failure to document laterality can lead to coding errors.

Mitigation Strategy

Implement a checklist to verify laterality is documented.

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 Sciatica Left Side, with expert answers to help guide accurate code selection and documentation.

Documentation Templates for Sciatica Left Side

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

Patient with left-sided sciatica

Specialty: Neurology

Required Elements

  • History of present illness
  • Physical exam findings
  • Imaging results
  • Assessment and plan

Example Documentation

**Subjective**: '72yo F reports 3-week history of electric shock-like pain from left buttock to lateral foot, rates 7/10. Symptoms worsen with prolonged sitting.' **Objective**: - Motor: Left EHL 4/5, left ankle dorsiflexion 4+/5 - Sensory: Decreased light touch left lateral calf - SLR: Positive left at 60° with calf pain reproduction - Imaging: MRI shows left L4-L5 disc bulge without central stenosis **Assessment**: 1. Left-sided sciatica (M54.32) 2. L4-L5 disc degeneration (M51.36) **Plan**: - PT referral for McKenzie exercises - Avoid repetitive flexion

Examples: Poor vs. Good Documentation

Poor Documentation Example
Patient has sciatica.
Good Documentation Example
Patient reports sharp pain radiating from lower back to left buttock and thigh, positive SLR test on left.
Explanation
The good example provides specific details about the pain, its location, and clinical test results, supporting the diagnosis.

Need help with ICD-10 coding for Sciatica Left Side? Ask your questions below.

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