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M96.1
ICD-10-CM
Lumbar Discectomy

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

Lumbar Diskectomy
Lumbar Disc Removal

Diagnosis Snapshot

Key Facts
  • Definition : Surgical removal of herniated disc material pressing on spinal nerves.
  • Clinical Signs : Low back pain, leg pain (sciatica), numbness, weakness, tingling.
  • Common Settings : Hospital operating room, outpatient surgical center.

Related ICD-10 Code Ranges

Complete code families applicable to AAPC M96.1 Coding
0SG00ZZ-0SG90ZZ

Removal of lumbar intervertebral disc

Excision of lumbar disc, open or percutaneous approach.

0SB00ZZ-0SB90ZZ

Spinal fusion of lumbar region

Fusion of lumbar spine, often combined with discectomy.

M510-M519

Intervertebral disc disorders lumbar

Conditions like herniated or prolapsed disc necessitating discectomy.

Code-Specific Guidance

Decision Tree for

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?

Code Comparison

Related Codes Comparison

When to use each related code

Description
Lumbar Discectomy
Lumbar Laminectomy
Lumbar Spinal Fusion

Documentation Best Practices

Documentation Checklist
  • Lumbar discectomy documentation: ICD-10 code, laterality
  • Pre-op diagnosis supporting lumbar discectomy procedure
  • Surgical approach details: anterior, posterior, minimally invasive
  • Intraoperative findings: disc level, herniation type
  • Post-op diagnosis, complications if any, discharge instructions

Coding and Audit Risks

Common Risks
  • Incorrect Code Level

    Coding lumbar discectomy with wrong approach code (open, percutaneous, endoscopic) or missing exploration/decompression codes leading to under/overpayment.

  • Unbundling Services

    Separate coding for components of lumbar discectomy like laminotomy/foraminotomy when included, violating NCCI edits and causing claim denials.

  • Lacking Documentation

    Insufficient operative report details (levels, approach, fusion) affecting accurate code assignment and potentially triggering audits/RAC reviews.

Mitigation Tips

Best Practices
  • Post-op PT, proper lifting techniques, and ergonomic workstation for Lumbar Discectomy (ICD-10-PCS 00N00Z0)
  • Timely follow-up, medication adherence, and pain management documentation improve CDI for lumbar discectomy
  • Ensure coding accuracy (CPT 63030, ICD-10 M51.06) for compliant billing of lumbar discectomy
  • Pain assessment scales (VAS, NRS) enhance clinical documentation for lumbar discectomy and improve compliance
  • Smoking cessation counseling improves surgical outcomes and reduces complications for lumbar discectomy patients

Clinical Decision Support

Checklist
  • Confirm radiculopathy correlating to disc level on MRI
  • Verify surgical indication documented (failed conservative Rx)
  • Cauda equina/progressive neuro deficit documented if present
  • Pre-op labs/imaging reviewed and documented
  • Surgical risks/benefits discussed and consent obtained

Reimbursement and Quality Metrics

Impact Summary
  • Lumbar Discectomy Reimbursement: Coding accuracy impacts DRG assignment and payment. Focus on ICD-10-PCS code specificity for optimal reimbursement.
  • Quality Metrics Impact: Postoperative complications like surgical site infections (SSI) affect hospital quality reporting and value-based payments.
  • Coding Accuracy: Correct coding of comorbidities (e.g., diabetes) using ICD-10-CM improves case mix index (CMI) and reimbursement.
  • Hospital Reporting: Accurate documentation and coding of discharge disposition impact readmission rates and hospital rankings.

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
  • Verify disc level, laterality
  • Document excision details
  • Code approach (open/percutaneous)
  • Check for separate decompression codes
  • Consider fusion if performed

Documentation Templates

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.
Lumbar Discectomy - AI-Powered ICD-10 Documentation