Find comprehensive information on Lumbar Discectomy, including clinical documentation requirements, medical coding guidelines (ICD-10-PCS, CPT codes), postoperative care, and healthcare resources. Learn about herniated disc treatment, discectomy recovery, surgical techniques, and potential complications. This resource offers valuable insights for healthcare professionals, medical coders, and patients seeking information on lumbar discectomy diagnosis and procedures.
Also known as
Removal of lumbar intervertebral disc
Excision of lumbar disc, open or percutaneous approach.
Spinal fusion of lumbar region
Fusion of lumbar spine, often combined with discectomy.
Intervertebral disc disorders lumbar
Conditions like herniated or prolapsed disc necessitating discectomy.
Follow this step-by-step guide to choose the correct ICD-10 code.
Is the discectomy routine?
Yes
Which lumbar level?
No
Is it for decompression?
When to use each related code
Description |
---|
Lumbar Discectomy |
Lumbar Laminectomy |
Lumbar Spinal Fusion |
Coding lumbar discectomy with wrong approach code (open, percutaneous, endoscopic) or missing exploration/decompression codes leading to under/overpayment.
Separate coding for components of lumbar discectomy like laminotomy/foraminotomy when included, violating NCCI edits and causing claim denials.
Insufficient operative report details (levels, approach, fusion) affecting accurate code assignment and potentially triggering audits/RAC reviews.
Patient presents with complaints of low back pain radiating to the leg, consistent with lumbar radiculopathy. Symptoms include sharp, burning, or stabbing pain in the lower back, buttocks, and down the leg, possibly extending to the foot. The patient reports experiencing numbness, tingling, and muscle weakness in the affected leg. Onset of symptoms is reported as gradual or sudden, potentially exacerbated by activities such as bending, lifting, or prolonged sitting. Physical examination reveals positive straight leg raise test, indicating nerve root tension. Neurological examination demonstrates sensory deficits and diminished reflexes in the affected dermatome and myotome. Magnetic resonance imaging MRI of the lumbar spine confirms the diagnosis of lumbar disc herniation at the L4-L5 or L5-S1 level, with nerve root compression. Conservative treatment options such as physical therapy, pain management, and epidural steroid injections were attempted but provided insufficient relief. Surgical intervention in the form of a lumbar discectomy is indicated to decompress the affected nerve root and alleviate symptoms. Risks and benefits of the procedure, including potential complications such as infection, bleeding, nerve damage, and recurrent disc herniation, were discussed with the patient, and informed consent was obtained. The patient is scheduled for a lumbar discectomy procedure. Postoperative care will include pain management, wound care, and physical therapy to facilitate recovery and restore function. Follow-up appointments will be scheduled to monitor healing and progress.