Find information on Herniated Nucleus Pulposus Lumbar including clinical documentation, medical coding, ICD-10 codes, diagnosis codes, and treatment options. This resource provides details on HNP Lumbar, lower back pain, radiculopathy, sciatica, and disc herniation for healthcare professionals, focusing on accurate medical coding and best practices for documentation. Learn about symptoms, diagnosis, and management of lumbar herniated disc.
Also known as
Other intervertebral disc displacement lumbar
Covers herniated lumbar discs at specific levels.
Lumbar and other intervertebral disc displacement w/ myelopathy
Lumbar disc herniation causing spinal cord compression.
Other intervertebral disc displacement other
Herniated discs in regions other than lumbar or with radiculopathy.
Intervertebral disc displacement unspecified
Herniated disc at an unspecified location.
Follow this step-by-step guide to choose the correct ICD-10 code.
Is the herniated nucleus pulposus at L1-L5?
Yes
With myelopathy?
No
Herniated nucleus pulposus is not at L1-L5. Refer to other sections of ICD-10-CM for appropriate code.
When to use each related code
| Description |
|---|
| Herniated lumbar disc |
| Lumbar spinal stenosis |
| Lumbar spondylosis |
Coding HNP Lumbar requires specifying laterality (right, left, or bilateral). Documentation discrepancies or missing laterality can lead to inaccurate codes.
Coding must capture the specific lumbar level(s) affected. Missing or unclear documentation of the level can lead to undercoding or overcoding.
Distinguishing between an acute exacerbation of a chronic HNP and an initial presentation impacts code selection and reimbursement. Documentation must clearly indicate this.
Patient presents with complaints consistent with lumbar herniated disc, also known as herniated nucleus pulposus (HNP) of the lumbar spine. Onset of low back pain is reported as [onset date or duration], characterized as [character of pain: e.g., sharp, dull, aching, burning]. Pain radiates to [location of radicular pain: e.g., right buttock, left leg, bilateral lower extremities], suggestive of radiculopathy. Patient reports [exacerbating factors: e.g., bending, lifting, sitting for prolonged periods] and [alleviating factors: e.g., lying down, ice, over-the-counter pain relievers]. Neurological examination reveals [positive or negative] straight leg raise test on the [left, right, or both] side(s). [Sensory/motor deficits: e.g., Diminished sensation in the lateral foot, weakness in dorsiflexion of the great toe] were noted. Differential diagnoses include lumbar strain, spinal stenosis, and degenerative disc disease. Assessment includes herniated nucleus pulposus L4-L5 vs. L5-S1. Plan includes MRI lumbar spine without contrast to confirm diagnosis and assess the extent of the herniation. Conservative management will be initiated with NSAIDs, physical therapy, and activity modification. Patient education provided on proper body mechanics and pain management strategies. Follow-up scheduled in [duration] to review MRI results and discuss further treatment options, including possible epidural steroid injection or surgical intervention if indicated. ICD-10 code: [Appropriate ICD-10 code, e.g., M51.16].