Low back pain is a commonly treated condition in the practice of physical therapy with several designations under low back pain ICD 10. In fact, a 2018 survey published by the Centers for Disease Control and Prevention (CDC) found that around 30% of adult men and women had experienced low back pain in the 3 months prior to the survey. Additionally, according to a recent fact sheet from the International Association for the Study of Pain, low back pain has remained the leading cause of years lost to disability since 1990. While studies show that amongst those living with low back pain, fewer than 1 in 3 experience significant participation restrictions for more than 6 months, low back pain remains a global health concern.
Symptoms of low back pain can vary from person to person but may include the following:
- Dull, achy, sharp, or burning pain in the posterior lower thorax near the spine or on either side of it
- Pain that radiates into the buttocks or into the thigh, lower leg or foot
- Pain in the low back that worsens with sitting and improves with movement
- Pain in the low back that worsens with movement and improves with rest.
Because of its prevalence, you will likely encounter this condition frequently in your practice and understanding how to correctly utilize the low back pain ICD 10 code is imperative for minimizing insurance claim denials. If you, like many therapists, have some experience searching for and selecting ICD-10 codes but don’t have a good understanding of the who, what, when and why these codes are used, see the next section for an low back pain ICD 10 code primer.
Following this introduction we will discuss the low back pain ICD10 code in more detail.
An introduction to low back pain ICD 10 codes
All HIPAA-covered entities are required to submit ICD-10 codes if seeking reimbursement for services from an insurance company. This includes physical therapists.
The International Classification of Disease, 10th Revision (ICD-10) is a set of diagnosis, symptom, and procedure codes that physical therapists use daily in their practice. In 2015 physical therapists and all other HIPAA-covered healthcare providers transitioned from the ICD-9 to the current version, ICD-10. ICD-10 codes are alphanumeric codes. They begin with a letter and are always between three and seven characters with a decimal point placed after the third character. The more characters it has, the more specific it is.
Each code follows the following structure:
Characters 1-3 indicate the category of the diagnosis;
Characters 4-6 indicate etiology, anatomic site, severity or other clinical detail;
Character 7 is an extension value, for example:
A: initial encounter (anything related to care of the initial injury);
D: subsequent encounter (anything related to the phase of routine care of the injury while the patient recovers–this usually refers to rehabilitation);
S: sequela (other conditions that may result from the presence of the primary condition).
Note, for fracture care, there are several more extensions (example: P, G, K, which signify malunion, delayed healing, or nonunion for a subsequent encounter).
ICD-10 codes must be submitted with relevant documentation whenever reimbursement is sought for covered services either by the healthcare entity itself or by a patient.
While it may seem like an extra step in an already detailed process of documentation and billing, ICD-10 codes are required for a specific reason. Not only do they identify a medical diagnosis, but perhaps more importantly, they help insurance companies understand why the care you are providing is medically necessary and therefore, reimbursable.
Low back pain (Dorsalgia) ICD 10: M54
When selecting low back pain ICD 10 codes, the low back pain ICD 10 code with the highest number of applicable characters should be chosen, at least on the first visit. Greater specificity is more likely to lead to reimbursement but it should always be supported by the patient’s medical record and clinical knowledge of the patient’s condition. Many three- and even sometimes four-digit codes can be found for a given condition when searching a reputable database like ICD10 Data but if a more detailed code is available, this low back pain ICD 10 code may not be reimbursable by insurance.
M54: Low back pain
To be used to describe acute or chronic low back pain in the thorax, lumbosacral region or adjacent regions. This code has not undergone any changes since 2015.
Is it billable?
This code should not be used for billing/reimbursement purposes as many other more specific low back pain ICD 10 codes exist.
How do I make it more specific?
See this reference for a complete list of billable and reimbursable codes related to low back pain M54.
- Specify site: M54.00-09
- Denote radiculopathy by site: M54.10-18
- Identify Sciatica by side: M54.3-32
- Unspecified low back pain: M54.50
- Other low back pain: M54.59
- Denote vertebrogenic origin: M54.51
When is an alternative code more appropriate?
Low back strain
Intervertebral disc disorders with myelopathy, lumbar region
Intervertebral disc disorders with radiculopathy, lumbar region
Intervertebral disc disorders with radiculopathy, lumbosacral region
Other intervertebral disc displacement, lumbar region
Other intervertebral disc displacement, lumbosacral region
Additional low back pain ICD 10 code considerations
As you can see, even simple low back pain ICD 10 codes can present a lot of choices.
When selecting a low back pain ICD 10 code, here are some additional considerations to help with successful reimbursement:
“Non specific” or “other” code: whenever possible avoid using these codes as the primary diagnosis code if a more detailed and specific code is available
- Unspecified low back pain: M54.50
- Other low back pain: M54.59
Place of occurrence codes (Y92): Place of occurrence codes may be used during the initial evaluation to increase specificity of the primary diagnosis.
Low back pain after working in the yard
Y92.017 Garden or yard in single-family (private) house as the place of occurrence of the external cause
Low back pain after working for a year at a factory
Y92.63 Factory as the place of occurrence of the external cause
External cause codes (V00-Y99): specify an external cause resulting in the episode of low back pain and may be used during the initial evaluation to increase specificity of the primary diagnosis.
Fall from a ladder
W11 Fall on and from ladder
V43 Car occupant injured in collision with car, pick-up truck or van
Stay up to date: The Centers for Medicare and Medicaid Services publish an updated list of codes each year to go into effect October 1 and remain in effect until September 30 of the following year. Sites like ICD10 Data can also be helpful in identifying code changes once they update their list as announced on their homepage.
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