Chronic low back pain (chronic LBP) diagnosis, medical coding, and clinical documentation guidelines for healthcare professionals. Learn about persistent low back pain (chronic lumbago) ICD-10 codes, treatment options, and best practices for accurate medical record keeping. Find resources for managing chronic LBP in clinical settings.
Also known as
Low back pain
Pain in the lower back, may be chronic or acute.
Lumbago with sciatica
Lower back pain radiating down the leg, often chronic.
Dorsalgia, unspecified
Unspecified back pain, which can include chronic lower back pain.
Follow this step-by-step guide to choose the correct ICD-10 code.
Is the low back pain chronic (12 weeks or longer)?
Yes
Is there radiculopathy or other neurological signs?
No
Do NOT code as chronic low back pain. Code the acute or subacute condition as appropriate.
When to use each related code
| Description |
|---|
| Lasting >12 weeks, non-specific low back pain. |
| Low back pain with nerve root compression. |
| Low back pain caused by lumbar disc degeneration. |
Coding chronic low back pain requires specific documentation of duration and etiology for accurate code assignment (e.g., M54.5 vs. other back pain codes).
Insufficient documentation linking chronic low back pain diagnosis to medical necessity of services provided can lead to denials.
Vague documentation using nonspecific terms like lumbago may hinder accurate code assignment and CDI efforts for chronic low back pain.
Q: What are the most effective evidence-based treatment strategies for managing chronic low back pain in patients resistant to initial conservative care?
A: For patients with chronic low back pain (CLBP) who haven't responded to initial conservative treatments like physical therapy and NSAIDs, a multidisciplinary approach is crucial. Evidence supports incorporating interventions such as cognitive behavioral therapy (CBT) for managing chronic pain, mindfulness-based stress reduction (MBSR) techniques, and interdisciplinary rehabilitation programs that address physical and psychosocial factors. Consider implementing a stepped-care approach, starting with less invasive options and escalating as needed, while always considering patient preferences and comorbidities. Explore how incorporating patient-specific functional goals can improve treatment adherence and outcomes in chronic LBP management. For cases with identifiable pathology, interventional procedures like epidural steroid injections or facet joint injections may be considered under careful selection criteria and with realistic expectations. Learn more about developing a personalized, comprehensive treatment plan for chronic low back pain resistant to initial therapy.
Q: How can clinicians differentiate between chronic low back pain with a specific underlying pathology and non-specific chronic low back pain to guide treatment decisions?
A: Differentiating between specific and non-specific chronic low back pain (CLBP) is crucial for effective treatment. Red flags like unexplained weight loss, night pain, fever, or neurological deficits warrant further investigation to rule out serious pathology such as spinal infection, malignancy, or cauda equina syndrome. A thorough history, physical examination focusing on neurological assessment, and imaging studies (X-ray, MRI, CT scan as clinically indicated) can help identify specific causes of CLBP like disc herniation, spinal stenosis, spondylolisthesis, or facet joint arthritis. However, most CLBP cases are non-specific, meaning a precise anatomical cause is not identifiable. In these instances, treatment focuses on functional restoration, pain management, and addressing psychosocial factors. Consider implementing validated screening tools like the STarT Back Screening Tool to stratify risk and tailor interventions to the individual patient's needs. Explore how integrating a biopsychosocial model can improve outcomes in patients with non-specific chronic low back pain.
Patient presents with chronic low back pain, consistent with a duration exceeding 12 weeks. The patient reports persistent lumbar pain, characterized as [character of pain: e.g., aching, burning, sharp] and localized to [location of pain: e.g., the lower back, radiating to the buttocks or legs]. Onset of pain was [onset: e.g., gradual, sudden] and is associated with [associated symptoms: e.g., stiffness, muscle spasms, numbness, tingling]. Aggravating factors include [aggravating factors: e.g., prolonged sitting, standing, bending, lifting]. Alleviating factors include [alleviating factors: e.g., rest, heat, medication]. The patient's pain intensity is reported as [pain scale rating] on a 0-10 numerical rating scale, impacting activities of daily living, including [impact on ADLs: e.g., sleep, work, exercise]. Physical examination reveals [physical exam findings: e.g., tenderness to palpation in the lumbar region, limited range of motion, positive straight leg raise test]. Neurological examination is [neurological exam findings: e.g., intact, with diminished reflexes in [location]]. Differential diagnoses considered include lumbar disc herniation, spinal stenosis, osteoarthritis, and facet joint syndrome. Current medications include [current medications]. Prior treatment includes [prior treatments: e.g., physical therapy, chiropractic care, injections]. Assessment: Chronic LBP (ICD-10: M54.5). Plan: Continue current medications. Recommend physical therapy focusing on core strengthening, flexibility, and pain management. Consider referral to pain management specialist if symptoms persist. Patient education provided on proper body mechanics, posture, and activity modification. Follow-up scheduled in [duration] to assess response to treatment.