Find information on lumbar disc herniation with radiculopathy, including clinical documentation, medical coding, ICD-10 codes, healthcare guidelines, and treatment options. Learn about symptoms, diagnosis, and management of this condition. Explore resources for healthcare professionals, including coding best practices for lumbar disc herniation with radiculopathy and related nerve root compression. This resource provides essential information for accurate documentation and coding of this lower back pain diagnosis.
Also known as
Lumbar and other intervertebral disc
Covers lumbar disc herniation with radiculopathy.
Radiculopathy, lumbar region
Specifies nerve root involvement in the lower back.
Chronic pain syndrome
May be used if chronic pain is a prominent feature.
Follow this step-by-step guide to choose the correct ICD-10 code.
Is the herniation confirmed by imaging?
Yes
Is there radiculopathy?
No
Insufficient documentation to code lumbar disc herniation. Query physician.
When to use each related code
Description |
---|
Lumbar Disc Herniation with Radiculopathy |
Lumbar Disc Herniation |
Lumbar Radiculopathy |
Lack of documentation detailing laterality, level, and type of herniation (e.g., protrusion, extrusion) can lead to inaccurate coding (M51.1x).
Insufficient documentation linking the lumbar disc herniation to the radiculopathy (e.g., nerve root impingement) may cause coding errors.
Missing or inadequate diagnostic confirmation (e.g., MRI findings) can lead to unsupported diagnosis coding, raising audit red flags.
Patient presents with complaints consistent with lumbar disc herniation with radiculopathy. Symptoms include low back pain radiating to the leg, described as sharp, burning, or electric-like. Onset of pain is reported as [onset - e.g., gradual, sudden, following lifting incident]. Patient reports [duration of symptoms - e.g., intermittent, constant] pain exacerbated by [exacerbating factors - e.g., coughing, sneezing, bending, prolonged sitting] and alleviated by [alleviating factors - e.g., rest, lying down]. Neurological examination reveals [positive or negative] straight leg raise test at [degrees] on the [right or left] side, producing pain radiating to the [distribution - e.g., buttock, posterior thigh, calf, foot]. Diminished [sensation or reflexes] noted in the [dermatome/myotome - e.g., L5, S1] distribution. Muscle weakness is [present or absent] in the [affected muscle groups - e.g., ankle dorsiflexion, great toe extension]. Patient denies bowel or bladder incontinence. Differential diagnoses include lumbar spinal stenosis, piriformis syndrome, and facet joint syndrome. Impression is lumbar disc herniation with radiculopathy at [level - e.g., L4-L5, L5-S1] based on clinical presentation and physical examination findings. Plan includes conservative management with NSAIDs, physical therapy, and activity modification. Imaging studies, such as MRI of the lumbar spine, may be considered to confirm the diagnosis and evaluate the extent of disc herniation. Neurosurgical consultation will be considered if symptoms persist or worsen despite conservative treatment, or if neurological deficits progress. Patient education provided regarding proper body mechanics, pain management strategies, and the natural history of lumbar disc herniation. Follow-up scheduled in [timeframe - e.g., two weeks] to assess response to treatment.