DocScrib
How it WorksPricingBlog
Sign InSign UpBook a Demo
DocScrib

AI-powered medical documentation platform streamlining healthcare workflows through intelligent transcription and clinical note generation.

Book a Demo

Product

  • Medical Templates
  • Pricing
  • Integrations
  • Security & Compliance

Resources

  • Blog
  • Documentation
  • Case Studies

Contact

  • support@docscrib.com
  • +1 (555) 123-4567
  • 123 Healthcare Blvd
    Medical District, CA 90210
© 2025 DocScrib. All rights reserved.
Privacy PolicyTerms of ServiceCookie Policy
Home/Diagnosis/ICD-10 Coding for Low Back Injury

ICD-10 Coding for Low Back Injury

S39.002A
M54.5

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

Also Known as:
Lower Back Injury
Lumbar Injury
Back Strain
Join 10,000+ Happy Clinicians

The AI Medical Scribe for Happiest Clinicians

Save 2+ hours daily with instant clinical documentation.
Our AI scribe listens, understands, and generates comprehensive medical notes so you can focus on patient care.

Start Free Trial
No credit card required•HIPAA compliant
Recording Controls
Start recording to see live transcription
Live Conversation - Try For Free!
Real-time transcription with automatic speaker identification

Ready to Record

Start recording to see live conversation transcription

Key Information: ICD-10 Coding for Low Back Injury

Essential facts and insights about ICD-10 Coding for Low Back Injury

Use ICD-10 code S39.002A for unspecified injury of muscle and tendon of lower back, initial encounter, ensuring proper documentation in clinical notes.

Primary ICD-10-CM Codes

Unspecified injury of muscle and tendon of lower back, initial encounter

Billable Code
S39.002A
Billable

Diagnostic Criteria

  • • Presence of muscle injury symptoms without specific strain details

Applicable To

  • • Unspecified muscle injury of lower back

Important Notes

  • • Ensure documentation specifies the nature of the injury to avoid defaulting to unspecified codes.

Low back pain

Non-Billable
M54.5
Non-Billable

Diagnostic Criteria

  • • Patient reports of pain localized to the lower back
  • • Absence of specific injury documentation

Applicable To

  • • Lumbago

Important Notes

  • • Ensure pain is the primary symptom and not secondary to a more specific diagnosis.
Ancillary Codes

Additional codes that may be used with this diagnosis

M54.5

Low back pain

Use to document associated pain symptoms.

Frequently Asked Questions

What is the ICD-10 code for low back injury?

The ICD-10 code for an unspecified low back injury is S39.002A. For specific strains, use S39.012A.

How do you code low back pain?

Low back pain is coded as M54.5 in ICD-10. Use this code when pain is the primary symptom without a specific injury.

Quick Navigation
All DiagnosesICD-10 Codes

Related Resources

How Medical Coding WorksBrowse All Codes