Find key information on Lumbosacral Disc Herniation including diagnosis codes (ICD-10 M51.1), clinical documentation requirements, healthcare provider resources, and medical coding guidelines. Learn about symptoms, treatment options, and best practices for documenting a Lumbosacral Disc Herniation diagnosis for accurate reimbursement and patient care. This resource provides essential information for physicians, coders, and other healthcare professionals dealing with lower back pain, radiculopathy, and intervertebral disc disorders.
Also known as
Lumbosacral disc herniation
Herniated disc in the lower back.
Lumbosacral disc displacement
Displaced disc in the lower back, not classified as herniation.
Other lumbosacral intervertebral disc degeneration
Degenerative changes in the lower back discs, excluding herniation and displacement.
Lumbago with sciatica
Lower back pain that radiates down the leg, often associated with disc herniation.
Follow this step-by-step guide to choose the correct ICD-10 code.
Is the herniation at L1-L4?
Yes
With myelopathy?
No
Is the herniation at L5-S1?
When to use each related code
Description |
---|
Lumbosacral disc herniation |
Lumbago |
Spinal stenosis lumbar |
Incorrect coding for the side of herniation (right, left, or bilateral) can lead to claim denials and inaccurate data.
Failing to code the specific lumbosacral level (e.g., L4-L5) impacts reimbursement and quality reporting.
Coding a decompression as an excision, or vice-versa, leads to inaccurate severity reflection and potential overpayment.
Patient presents with complaints consistent with lumbosacral disc herniation. Symptoms include low back pain radiating to the leg, described as sciatica or radicular pain. Onset of pain is reported as [onset timeframe - e.g., gradual, sudden, following lifting incident]. Pain quality is described as [pain quality descriptors - e.g., sharp, burning, aching, electric]. Exacerbating factors include [exacerbating factors - e.g., bending, lifting, sitting, coughing, sneezing]. Alleviating factors include [alleviating factors - e.g., lying down, rest, medication]. Associated symptoms may include numbness, tingling, and weakness in the [affected leg/foot area - e.g., right leg, left foot]. Physical examination reveals [positive or negative] straight leg raise test on the [affected side] at [degrees of elevation], reproducing radicular symptoms. Neurological examination demonstrates [sensory/motor deficits - e.g., diminished patellar reflex, decreased sensation in dermatome L5]. Differential diagnoses considered include lumbar spinal stenosis, piriformis syndrome, and facet joint pain. Assessment: Lumbosacral disc herniation at [level - e.g., L4-L5, L5-S1] is suspected. Plan: Conservative management is initiated, including NSAIDs for pain relief, physical therapy for core strengthening and lumbar stabilization exercises, and patient education on proper body mechanics. Imaging studies, such as MRI of the lumbar spine, are ordered to confirm the diagnosis and evaluate the extent of the herniation. Follow-up appointment scheduled in [timeframe - e.g., two weeks] to assess response to treatment. Referral to a neurosurgeon or pain management specialist will be considered if symptoms persist or worsen despite conservative measures.