Find information on sciatica pain diagnosis, including clinical documentation, medical coding (ICD-10-CM M54.1, M54.10, M54.11, M54.12), radiculopathy, lumbar radiculopathy, nerve root compression, and lower back pain symptoms. Learn about healthcare provider resources for accurate sciatica diagnosis and treatment options. This resource offers guidance for proper medical coding and documentation related to sciatica for healthcare professionals.
Also known as
Sciatica
Pain radiating along the sciatic nerve.
Lumbago with sciatica
Lower back pain combined with sciatic nerve pain.
Nerve root and plexus compressions
Compressed nerves, which can cause sciatica-like symptoms.
Neuralgia and neuritis, unspecified
General nerve pain that may include sciatica if not specified further.
Follow this step-by-step guide to choose the correct ICD-10 code.
Is the sciatica due to a herniated disc?
Yes
Confirmed by imaging?
No
Is there lumbar spinal stenosis?
When to use each related code
Description |
---|
Sciatica pain radiating down the leg |
Lumbar spinal stenosis |
Piriformis syndrome |
Lack of laterality (right/left) or specific radiating site documentation can lead to unspecified sciatica coding (M54.3) impacting reimbursement.
Failure to document the underlying cause of sciatica (e.g., herniated disc) can lead to inaccurate coding and underreporting severity for quality metrics.
Vague documentation like low back pain with radiation down leg may be insufficient to justify a specific sciatica diagnosis and code (M54.4).
Patient presents with complaints consistent with sciatica pain. Symptoms include lower back pain radiating down the leg, described as sharp, burning, or shooting. The patient reports pain radiating to the buttock, thigh, and posterior calf, occasionally extending to the foot. Onset of sciatica symptoms is reported as gradual, potentially exacerbated by prolonged sitting, bending, or lifting. Physical examination reveals tenderness to palpation along the sciatic nerve distribution. Positive straight leg raise test elicits radicular pain. Neurological examination demonstrates possible sensory deficits, including numbness, tingling, or weakness in the affected leg. Differential diagnosis includes lumbar disc herniation, spinal stenosis, piriformis syndrome, and degenerative disc disease. Assessment suggests sciatica, likely secondary to lumbar radiculopathy. Plan includes conservative management with NSAIDs for pain relief, physical therapy for core strengthening and flexibility exercises, and patient education on proper body mechanics. Referral to pain management or spine specialist will be considered if symptoms persist or worsen. Follow-up scheduled in two weeks to assess response to treatment. ICD-10 code M54.3, low back pain with sciatica, is assigned. CPT codes for evaluation and management, physical therapy, and potential imaging studies will be documented based on services provided.