Coming Soon
Find information on Low Back Pain with Radiculopathy including clinical documentation, medical coding, ICD-10 codes, diagnosis codes, treatment, and prognosis. Learn about radicular pain, nerve root compression, lumbar radiculopathy symptoms, and sciatica related to low back pain. This resource offers guidance for healthcare professionals on accurate coding and documentation for Low Back Pain with Radiculopathy. Explore resources related to differential diagnosis and evidence-based management of this condition.
Also known as
Radiculopathy, lumbar region
Low back pain caused by pinched nerves.
Lumbar spinal stenosis
Narrowing of the spinal canal causing back and leg pain.
Lumbosacral spondylosis
Degenerative changes in the lower spine causing pain.
Follow this step-by-step guide to choose the correct ICD-10 code.
Is the low back pain with radiculopathy due to a traumatic injury?
When to use each related code
| Description |
|---|
| Low Back Pain with Radiculopathy |
| Lumbar Spinal Stenosis |
| Lumbar Disc Herniation |
Lack of documentation specifying laterality (right, left, bilateral) and the affected nerve root for accurate M54.1x code selection.
Insufficient clinical evidence in documentation to support radiculopathy diagnosis, leading to potential upcoding from M54.5 (low back pain).
Unclear documentation linking low back pain with the identified radiculopathy, impacting accurate code assignment and reimbursement.
Patient presents with complaints of low back pain radiating to the leg, consistent with lumbar radiculopathy. Onset of symptoms occurred approximately [duration] ago and is described as [quality of pain: e.g., sharp, burning, aching, electric]. The pain is exacerbated by [exacerbating factors: e.g., bending, lifting, sitting, standing] and relieved by [relieving factors: e.g., rest, medication, ice, heat]. The patient reports pain radiating down the [affected leg: right, left] along the [dermatomal distribution: e.g., L5, S1] dermatome. Associated symptoms include [associated symptoms: e.g., numbness, tingling, weakness, muscle spasms]. Physical examination reveals [positive findings: e.g., positive straight leg raise test, decreased reflexes, muscle weakness, sensory deficits]. Neurological examination indicates [neurological findings: e.g., diminished reflexes, dermatomal sensory loss]. The patient denies [pertinent negatives: e.g., bowel or bladder incontinence, saddle anesthesia]. Differential diagnoses include lumbar disc herniation, spinal stenosis, degenerative disc disease, and facet joint syndrome. Assessment points to low back pain with radiculopathy, likely secondary to [suspected etiology: e.g., disc herniation]. Plan includes [diagnostic testing: e.g., MRI lumbar spine], [pharmacological treatment: e.g., NSAIDs, muscle relaxants, neuropathic pain medication], [physical therapy: e.g., core strengthening exercises, stretching], and [referral if necessary: e.g., referral to pain management specialist, neurosurgery]. Patient education provided on proper body mechanics, activity modification, and pain management strategies. Follow-up scheduled in [duration] to assess response to treatment.