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M51.16
ICD-10-CM
Lumbar Disc Herniation with Radiculopathy

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

Herniated Disc with Sciatica
Slipped Disc with Nerve Pain

Diagnosis Snapshot

Key Facts
  • Definition : Protrusion of a lumbar spinal disc, compressing a nerve root.
  • Clinical Signs : Low back pain radiating to leg, numbness, tingling, weakness, sciatica.
  • Common Settings : Outpatient clinics, physical therapy, pain management, spine surgery.

Related ICD-10 Code Ranges

Complete code families applicable to AAPC M51.16 Coding
M51.1-

Lumbar and other intervertebral disc

Covers lumbar disc herniation with radiculopathy.

M54.1-

Radiculopathy, lumbar region

Specifies nerve root involvement in the lower back.

G89.2-

Chronic pain syndrome

May be used if chronic pain is a prominent feature.

Code-Specific Guidance

Decision Tree for

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.

Code Comparison

Related Codes Comparison

When to use each related code

Description
Lumbar Disc Herniation with Radiculopathy
Lumbar Disc Herniation
Lumbar Radiculopathy

Documentation Best Practices

Documentation Checklist
  • Lumbar disc herniation diagnosis code
  • Radiculopathy documentation ICD-10
  • Specific nerve root affected
  • Laterality (left/right) documented
  • Pain, numbness, weakness details

Coding and Audit Risks

Common Risks
  • Code Specificity

    Lack of documentation detailing laterality, level, and type of herniation (e.g., protrusion, extrusion) can lead to inaccurate coding (M51.1x).

  • Radiculopathy Clarity

    Insufficient documentation linking the lumbar disc herniation to the radiculopathy (e.g., nerve root impingement) may cause coding errors.

  • Clinical Validation

    Missing or inadequate diagnostic confirmation (e.g., MRI findings) can lead to unsupported diagnosis coding, raising audit red flags.

Mitigation Tips

Best Practices
  • ICD-10 M51.1, accurate CDI for lumbar disc herniation with radiculopathy.
  • Document nerve root compression signs/symptoms, laterality, for compliance.
  • Physical therapy, pain management for initial conservative treatment, record progress.
  • Consider ESI, surgery if conservative therapy fails, justify medical necessity.
  • Regular follow-up, reassessment, and documentation essential for improved outcomes.

Clinical Decision Support

Checklist
  • Verify low back pain with radiating leg pain
  • Confirm sensory/motor deficit matching nerve root
  • Positive straight leg raise or slump test documented
  • Image (MRI/CT) confirms herniated disc at level
  • Correlate imaging findings with clinical symptoms

Reimbursement and Quality Metrics

Impact Summary
  • Lumbar Disc Herniation with Radiculopathy reimbursement hinges on accurate ICD-10 (M51.1x) and CPT coding (e.g., 64483, 64484) for procedures like epidural injections or discectomies. Proper coding maximizes payment and minimizes denials.
  • Quality metrics impacted: Patient-reported pain scores, Oswestry Disability Index (ODI), functional status improvement, and medication usage post-intervention. These metrics directly influence hospital value-based payments.
  • Coding accuracy for Lumbar Disc Herniation with Radiculopathy affects hospital reporting on surgical complications, readmission rates, and length of stay, impacting public quality scores and reimbursement.
  • Timely claim submission and appropriate modifier usage are crucial for optimal reimbursement for Lumbar Disc Herniation. Delays or incorrect modifiers can lead to lower payments and claim denials.

Streamline Your Medical Coding

Let S10.AI help you select the most accurate ICD-10 codes. Our AI-powered assistant ensures compliance and reduces coding errors.

Quick Tips

Practical Coding Tips
  • Code specific nerve root
  • Document pain radiation
  • Specify laterality (left/right)
  • Include symptom duration
  • Consider imaging confirmation

Documentation Templates

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.
Lumbar Disc Herniation with Radiculopathy - AI-Powered ICD-10 Documentation