Find information on Low Back Pain Unspecified, including ICD-10 code M545, diagnosis codes, clinical documentation requirements, and medical coding guidelines. Learn about common symptoms, differential diagnoses, and treatment options for nonspecific low back pain. This resource provides valuable insights for healthcare professionals, medical coders, and billers seeking accurate and efficient documentation and coding practices related to low back pain.
Also known as
Low back pain
Pain in the lower back, unspecified.
Lumbago with sciatica
Lower back pain radiating down the leg.
Dorsalgia, unspecified
Pain in the back, not otherwise specified.
Other dorsalgia
Other specified back pain, excluding low back.
Follow this step-by-step guide to choose the correct ICD-10 code.
Is the low back pain related to trauma?
Yes
Is there a fracture?
No
Is there radiculopathy?
When to use each related code
| Description |
|---|
| Low Back Pain Unspecified |
| Lumbago with Sciatica |
| Intervertebral Disc Displacement Lumbar |
Overuse of M54.5, Low Back Pain Unspecified, when more specific diagnoses are documented, impacting data accuracy and reimbursement.
Lack of sufficient documentation to support M54.5, leading to coding errors, denials, and compliance risks during audits.
Coding M54.5 without establishing medical necessity for tests or procedures, creating potential audit and fraud risks.
Q: What are the most effective differential diagnosis strategies for non-specific low back pain in primary care, considering red flags and mimicking conditions?
A: Diagnosing non-specific low back pain (NSLBP) in primary care requires a systematic approach to rule out serious pathology (red flags) and mimicking conditions. Begin with a thorough history, focusing on pain characteristics, onset, duration, aggravating and relieving factors, and any associated symptoms. Physical examination should assess range of motion, neurological function (reflexes, sensation, strength), and palpation for tenderness. Red flags like unexplained weight loss, fever, night pain, bowel/bladder changes, saddle anesthesia, or progressive neurological deficits necessitate urgent investigation (e.g., MRI, blood tests). Mimicking conditions such as ankylosing spondylitis, spinal stenosis, or facet joint syndrome require specific examination maneuvers and imaging if clinically suspected. Consider implementing validated screening tools like the STarT Back Screening Tool to stratify risk and guide management. Explore how incorporating these strategies can improve diagnostic accuracy and patient outcomes in NSLBP.
Q: How can clinicians effectively communicate prognosis and manage patient expectations for patients with chronic non-specific low back pain, given the often unpredictable nature of the condition?
A: Managing patient expectations in chronic non-specific low back pain (CNSLBP) hinges on clear and realistic communication. Explain that CNSLBP is often a persistent condition with variable trajectories. Emphasize that while a complete cure may not be possible, the goal is to improve function and quality of life. Discuss the biopsychosocial model of pain, explaining the interplay of physical, psychological, and social factors in pain perception and experience. Encourage active participation in self-management strategies, such as exercise, pacing activities, and stress reduction techniques. Learn more about evidence-based approaches to patient education and shared decision-making in CNSLBP to foster a positive therapeutic alliance and empower patients in their recovery journey.
Patient presents with complaints of low back pain, unspecified. Onset of lumbago is reported as [Date of Onset] and characterized as [Character of pain: e.g., aching, sharp, burning, radiating]. Pain severity is rated as [Pain Scale Rating: e.g., 0-10] with exacerbating factors including [Exacerbating factors: e.g., bending, lifting, prolonged sitting] and alleviating factors including [Alleviating factors: e.g., rest, ice, heat]. Patient denies [Pertinent negatives: e.g., bowel or bladder incontinence, saddle anesthesia, fever, chills]. Physical examination reveals [Objective findings: e.g., tenderness to palpation in the lumbar paraspinal muscles, limited range of motion in lumbar flexion and extension, negative straight leg raise test]. Neurological examination of the lower extremities is unremarkable. Differential diagnosis includes lumbar strain, lumbar sprain, mechanical low back pain, facet joint syndrome, and degenerative disc disease. Initial treatment plan includes [Treatment plan: e.g., conservative management with NSAIDs, ice/heat therapy, physical therapy referral for core strengthening and stretching exercises]. Patient education provided on proper body mechanics, activity modification, and pain management strategies. Follow up scheduled in [Duration] to reassess symptoms and response to treatment. ICD-10 code M54.5 Low back pain, unspecified is assigned. Medical necessity for services rendered is documented.