Find information on lumbar spine pain diagnosis, including clinical documentation, medical coding, and ICD-10 codes. Learn about common causes of low back pain, such as lumbar spondylosis, herniated disc, and spinal stenosis. Explore treatment options, differential diagnoses, and best practices for healthcare professionals documenting and coding lumbar spine pain in medical records. This resource provides guidance on accurate pain management coding and documentation for optimal reimbursement.
Also known as
Low back pain
Pain localized to the lower back region.
Lumbago with sciatica
Low back pain radiating down the leg.
Dorsalgia, unspecified
Back pain not otherwise specified.
Thoracic lumbago
Pain in the lower thoracic and lumbar spine regions.
Follow this step-by-step guide to choose the correct ICD-10 code.
Is the pain due to trauma/fracture?
When to use each related code
| Description |
|---|
| Pain in Lumbar Spine |
| Lumbago |
| Sciatica |
Coding lumbar spine pain without specific laterality or vertebral level may lead to claim denials. Proper documentation is crucial for accurate code assignment (e.g., M54.5). Medical coding, CDI, healthcare compliance.
Confusing radicular pain (M54.1) with general lumbar pain (M54.5) can impact reimbursement. Accurate diagnosis coding is essential for compliance. Medical coding, CDI, radiculopathy.
Failing to code the underlying cause of lumbar spine pain (e.g., disc herniation) can lead to underpayment. Complete documentation is key for appropriate coding. Medical coding, CDI, healthcare compliance.
Patient presents with complaints of low back pain, also described as lumbar pain or lumbago. Onset of pain is reported as [Onset - e.g., gradual, acute, insidious]. Patient characterizes the pain as [Character - e.g., sharp, dull, aching, burning, radiating] and localized to the [Location - e.g., lower lumbar region, radiating to buttock, radiating down the leg]. Pain severity is rated as [Severity - e.g., mild, moderate, severe] on a scale of 0-10. Aggravating factors include [Aggravating factors - e.g., bending, lifting, prolonged sitting, standing]. Alleviating factors include [Alleviating factors - e.g., rest, ice, heat, medication]. Patient denies [Pertinent negatives - e.g., bowel or bladder incontinence, saddle anesthesia, fever, chills]. Physical examination reveals [Physical exam findings - e.g., tenderness to palpation in the lumbar spine, limited range of motion, positive straight leg raise test]. Neurological examination is [Neurological exam findings - e.g., intact, reveals diminished sensation in the [dermatome], decreased reflexes in the [reflex]]. Differential diagnoses include lumbar strain, lumbar spondylosis, herniated disc, spinal stenosis, and sciatica. Assessment: Pain in lumbar spine, likely due to [Likely etiology - e.g., musculoskeletal strain, possible disc herniation]. Plan: Conservative management with [Treatment plan - e.g., NSAIDs, physical therapy, activity modification]. Patient education provided on proper body mechanics and pain management strategies. Follow-up scheduled in [Duration - e.g., two weeks] to assess response to treatment. Referral to [Specialist - e.g., orthopedics, pain management] will be considered if symptoms do not improve.