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M54.5
ICD-10-CM
Pain in Lumbar Spine

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
Lumbago
Lumbar Pain

Diagnosis Snapshot

Key Facts
  • Definition : Discomfort or pain in the lower back area.
  • Clinical Signs : Muscle spasms, stiffness, limited range of motion, radiating pain.
  • Common Settings : Primary care, orthopedics, physical therapy, chiropractic.

Related ICD-10 Code Ranges

Complete code families applicable to AAPC M54.5 Coding
M54.5

Low back pain

Pain localized to the lower back region.

M54.4

Lumbago with sciatica

Low back pain radiating down the leg.

M54.9

Dorsalgia, unspecified

Back pain not otherwise specified.

M51.1

Thoracic lumbago

Pain in the lower thoracic and lumbar spine regions.

Code-Specific Guidance

Decision Tree for

Follow this step-by-step guide to choose the correct ICD-10 code.

Is the pain due to trauma/fracture?

Code Comparison

Related Codes Comparison

When to use each related code

Description
Pain in Lumbar Spine
Lumbago
Sciatica

Documentation Best Practices

Documentation Checklist
  • Lumbar pain onset date, duration, character
  • Location, radiation of lumbar pain
  • Aggravating and relieving factors
  • Physical exam: ROM, tenderness, neuro
  • Impact on ADLs, work, sleep

Coding and Audit Risks

Common Risks
  • Unspecified Pain Location

    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.

  • Radiculopathy vs. Pain

    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.

  • Underlying Cause Uncoded

    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.

Mitigation Tips

Best Practices
  • Document precise location, radiation, and character of pain for accurate ICD-10 coding (M54.5).
  • Capture pain onset, duration, and exacerbating/relieving factors for improved CDI and HCC coding.
  • Assess impact on ADLs to support medical necessity and justify treatment plans for compliance.
  • Query physician for clarity if documentation lacks detail for specific lumbar spine diagnoses (e.g., spondylosis).
  • Correlate imaging findings with clinical presentation to ensure diagnostic accuracy and compliant billing.

Clinical Decision Support

Checklist
  • Verify radicular pain symptoms (ICD-10 M54.1)
  • Assess cauda equina syndrome red flags (patient safety)
  • Review imaging studies (MRI lumbar spine) for correlation
  • Document physical exam findings (neurological assessment)

Reimbursement and Quality Metrics

Impact Summary
  • Pain in Lumbar Spine reimbursement impacts coding accuracy, medical billing, and hospital reporting.
  • Accurate lumbar spine pain diagnosis coding maximizes reimbursement and reduces claim denials.
  • Quality metrics for low back pain management affect hospital value-based payments.
  • Coding validity for lumbar spine pain influences physician performance reporting.

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
  • Code specific lumbar pain location
  • Document pain radiation clearly
  • Consider underlying causes, code them too
  • Check Excludes1 notes for M54.5
  • Verify medical necessity for imaging codes

Documentation Templates

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.