Find information on lumbar pain with radiculopathy, including clinical documentation tips, medical coding guidelines, and healthcare resources. Learn about ICD-10 codes for lumbar radiculopathy, radicular pain, sciatica, and pinched nerve. Explore effective documentation strategies for lower back pain with nerve root compression, neurological deficits, and sensory or motor dysfunction. This resource helps healthcare professionals accurately document and code lumbar pain with radiculopathy for optimal reimbursement and patient care.
Also known as
Radiculopathy, lumbar region
Pain radiating along a nerve root in the lower back.
Lumbago with sciatica
Lower back pain with pain radiating down the leg.
Low back pain
Pain localized to the lower back region.
Chronic pain syndrome
Long-lasting pain that may be associated with nerve damage.
Follow this step-by-step guide to choose the correct ICD-10 code.
Is the radiculopathy due to a herniated disc?
Yes
Is there myelopathy?
No
Is it due to spinal stenosis?
When to use each related code
Description |
---|
Lumbar Pain with Radiculopathy |
Lumbar Spinal Stenosis |
Lumbar Disc Displacement |
Using unspecified lumbar pain codes (e.g., M54.9) when documentation supports radiculopathy (e.g., M54.1). Impacts reimbursement and data accuracy.
Missing documentation of affected side (right, left, bilateral) for radiculopathy. Required for accurate coding and proper billing.
Insufficient clinical evidence to support the diagnosis of lumbar radiculopathy, leading to potential denials and compliance issues.
Patient presents with chief complaint of lumbar pain radiating to the leg, consistent with lumbar radiculopathy. Symptoms include lower back pain, sciatica, radiating pain down the leg, numbness, tingling, and muscle weakness. Onset of pain was [Date of Onset] and is described as [Character of Pain: e.g., sharp, burning, aching]. Pain is aggravated by [Aggravating Factors: e.g., bending, lifting, sitting] and alleviated by [Alleviating Factors: e.g., rest, ice, heat]. Patient reports [Frequency and Duration of Pain: e.g., constant, intermittent, lasting X minutes/hours]. Physical examination reveals [Objective Findings: e.g., positive straight leg raise test, diminished reflexes, muscle weakness in [Affected Muscle Group], limited range of motion in the lumbar spine]. Neurological examination demonstrates [Specific Neurological Findings: e.g., sensory deficits in [Affected Dermatome], motor deficits in [Affected Myotome]]. Differential diagnosis includes herniated disc, spinal stenosis, degenerative disc disease, and facet joint syndrome. Assessment is lumbar radiculopathy, likely secondary to [Suspected Etiology: e.g., herniated disc at L4-L5]. Plan includes [Treatment Plan: e.g., conservative management with physical therapy, NSAIDs, referral to pain management, consideration for MRI lumbar spine to confirm diagnosis and rule out other pathologies]. Patient education provided regarding proper body mechanics, activity modification, and pain management strategies. Follow-up scheduled in [Duration] to assess response to treatment.