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Home/Diagnosis/ICD-10 Coding for Failed Back Surgery Syndrome

ICD-10 Coding for Failed Back Surgery Syndrome

M96.1

Complete ICD-10-CM coding and documentation guide for icd-10 coding for failed back surgery syndrome includes clinical validation requirements, medical necessity guidelines, and coding policies.

Also Known as:
Postlaminectomy Syndrome
Persistent Spinal Pain Syndrome
Post-surgical Spine Syndrome
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Key Information: ICD-10 Coding for Failed Back Surgery Syndrome

Essential facts and insights about ICD-10 Coding for Failed Back Surgery Syndrome

Use ICD-10 code M96.1 for postlaminectomy syndrome, ensuring proper documentation in clinical notes.

Primary ICD-10-CM Codes

Postlaminectomy syndrome

Billable Code
M96.1
Billable

Diagnostic Criteria

clinical:
  • • Persistent pain post-surgery with imaging evidence
documentation:
  • • Explicit mention of prior spinal surgery

Applicable To

  • • Failed back surgery syndrome

Important Notes

  • • Ensure documentation explicitly links symptoms to prior surgery.
Ancillary Codes

Additional codes that may be used with this diagnosis

M54.5

Low back pain

Use if axial pain predominates.

G89.4

Chronic pain syndrome

Add if pain persists >3 months with functional impairment.

Frequently Asked Questions

What is the ICD-10 code for failed back surgery syndrome?

The ICD-10 code for failed back surgery syndrome is M96.1, which is used for postlaminectomy syndrome when symptoms are linked to prior spinal surgery.

How is failed back surgery syndrome documented?

Documentation for failed back surgery syndrome should include a history of spinal surgery, imaging findings like epidural fibrosis, and explicit mention of postlaminectomy syndrome.

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