Find information on sciatica diagnosis, including clinical documentation and medical coding for sciatic nerve pain. Learn about ICD-10 codes for sciatica, lumbar radiculopathy, and related lower back pain conditions. This resource covers healthcare provider guidelines for documenting sciatica symptoms, physical exam findings, and diagnostic testing, such as MRI and EMG. Explore treatment options and best practices for managing sciatic nerve pain in a clinical setting.
Also known as
Sciatica
Pain radiating along the sciatic nerve.
Lumbosacral radiculopathy
Nerve root compression in the lower spine.
Neuralgia and neuritis, unspecified
Nerve pain not otherwise specified.
Other mononeuropathies of lower limb
Damage to a single nerve in the leg, not sciatica.
Follow this step-by-step guide to choose the correct ICD-10 code.
Is sciatic pain due to trauma?
Yes
Current injury?
No
Due to a Lumbosacral radiculopathy?
When to use each related code
Description |
---|
Sciatic nerve pain |
Lumbar spinal stenosis |
Piriformis syndrome |
Missing or incorrect laterality (right, left, bilateral) for sciatic nerve pain impacts reimbursement and data accuracy. ICD-10 requires specificity.
Unspecified sciatica (M54.3) lacks detail. Coders must query physicians for underlying cause (e.g., herniated disc) for proper coding and CDI.
Sciatica diagnoses have Excludes1 notes. Coders must ensure no conflicting diagnoses are coded, impacting medical necessity and compliance audits.
Patient presents with complaints consistent with sciatic nerve pain, also known as sciatica. Symptoms include lower back pain radiating down the leg, described as a burning, tingling, or shooting sensation. The pain follows the path of the sciatic nerve, extending through the buttock, thigh, and potentially to the foot. Onset of symptoms was reported as [Onset timeframe - e.g., gradual over several weeks, sudden after lifting heavy object]. Patient reports [Severity - e.g., mild, moderate, severe] pain impacting [Activities of daily living - e.g., walking, sitting, sleeping]. Physical examination reveals [Objective findings - e.g., tenderness to palpation along the sciatic nerve, positive straight leg raise test, decreased reflexes]. Differential diagnosis includes lumbar disc herniation, piriformis syndrome, spinal stenosis, and sacroiliac joint dysfunction. Assessment suggests sciatica likely due to [Suspected cause - e.g., lumbar disc herniation at L4-L5]. Plan includes [Treatment plan - e.g., conservative management with NSAIDs, physical therapy referral, MRI lumbar spine to confirm diagnosis, consideration for corticosteroid injection if symptoms persist]. Patient education provided on sciatica management, proper body mechanics, and activity modification. Follow-up scheduled in [Follow-up timeframe - e.g., two weeks] to assess response to treatment. ICD-10 code: M54.3. CPT codes for evaluation and management, and any procedures performed, will be documented separately.