Chronic Lower Back Pain (Chronic LBP) diagnosis, clinical documentation, and medical coding information for healthcare professionals. Find resources for Chronic lumbosacral pain and Persistent Low Back Pain including ICD-10 codes, treatment options, and best practices for accurate medical record keeping. This comprehensive guide helps clinicians effectively document and code C Chronic Lower Back Pain.
Also known as
Low back pain
Pain in the lower back region.
Lumbago with sciatica
Lower back pain radiating down the leg.
Dorsalgia, unspecified
Back pain not otherwise specified.
Follow this step-by-step guide to choose the correct ICD-10 code.
Is the lower back pain chronic (12+ weeks)?
Yes
Is there radiculopathy or other neurological signs?
No
Do NOT code as chronic. Code the acute lower back pain diagnosis based on presenting symptoms.
When to use each related code
| Description |
|---|
| Lasting >12 weeks, not fully explained by other conditions. |
| LBP with nerve root involvement, causing pain, numbness, weakness. |
| LBP caused by spinal stenosis, narrowing the spinal canal. |
Coding C. Chronic Lower Back Pain lacks laterality and anatomical detail, impacting reimbursement and data analysis. CDI can clarify.
Coding C. Chronic Lower Back Pain without addressing the etiology (e.g., disc herniation) risks underpayment and inaccurate reporting.
Documentation must support the medical necessity for treatment related to C. Chronic Lower Back Pain to ensure compliance and avoid denials.
Q: What are the most effective evidence-based treatment strategies for managing chronic lower back pain in older adults with comorbidities?
A: Managing chronic lower back pain (CLBP) in older adults with comorbidities requires a multifaceted, individualized approach. Evidence-based treatments emphasize non-pharmacological interventions as first-line options. These include exercise therapy focusing on core strengthening and flexibility, mind-body practices like yoga and tai chi, and manual therapy such as spinal manipulation or mobilization. Consider implementing a combination of these approaches tailored to the patient's specific functional limitations and comorbidities. For instance, aquatic therapy might be suitable for patients with osteoarthritis, while cognitive behavioral therapy can help address pain catastrophizing and improve coping mechanisms. Pharmacological management should be considered judiciously, starting with acetaminophen and topical analgesics, progressing to NSAIDs or opioids only when necessary and with careful monitoring due to increased risk of adverse events in this population. Explore how interdisciplinary pain management programs can provide comprehensive care encompassing physical, psychological, and social aspects of CLBP in complex older adult patients. Learn more about specific exercise modifications and precautions based on individual comorbid conditions.
Q: How can clinicians differentiate between chronic lower back pain with a radicular component and chronic lumbosacral pain with referred pain, and what diagnostic tests are most helpful in each case?
A: Differentiating between chronic lower back pain with a radicular component and chronic lumbosacral pain with referred pain hinges on a thorough neurological examination and appropriate diagnostic testing. Radicular pain, often caused by nerve root compression, typically presents with dermatomal sensory changes (e.g., numbness, tingling), myotomal weakness, and diminished deep tendon reflexes. Referred pain, on the other hand, originates from a different structure but is perceived in the lower back region, lacking the specific neurological findings associated with radicular pain. A straight-leg raise test can be helpful in identifying nerve root involvement. Imaging studies like MRI can confirm disc herniation or spinal stenosis contributing to radicular pain. Consider implementing electrodiagnostic studies (EMG/NCS) to assess nerve function and pinpoint the affected nerve root if the diagnosis remains unclear. For referred pain, diagnostic tests depend on the suspected underlying cause and may include X-rays, CT scans, or ultrasound for assessing musculoskeletal structures, or further investigations for visceral sources of pain. Learn more about the clinical presentation and diagnostic criteria for various causes of referred lumbosacral pain.
Patient presents with chronic lower back pain (CLBP), also referred to as chronic LBP or persistent low back pain, of greater than 12 weeks duration. Onset was insidious and patient reports no specific inciting event. Pain is described as a dull ache, localized to the lumbosacral region, with occasional radiation to the buttocks. Pain severity is reported as 5/10 on average, with exacerbations to 7/10 during periods of increased activity. Associated symptoms include stiffness and limited range of motion. Aggravating factors include prolonged standing, sitting, and lifting. Alleviating factors include rest, heat application, and over-the-counter analgesics such as ibuprofen. Patient denies any radicular symptoms, bowel or bladder dysfunction, or history of trauma. Physical examination reveals tenderness to palpation in the lumbar paraspinal muscles and reduced lumbar flexion and extension. Neurological examination is unremarkable. Assessment: Chronic lower back pain, unspecified (ICD-10 M54.5). Plan: Conservative management including patient education on proper body mechanics, home exercise program focusing on core strengthening and stretching, and NSAIDs for pain management. Referral to physical therapy for further evaluation and treatment. Follow up in 4 weeks to assess response to treatment and consider further diagnostic testing if indicated.