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Home/Diagnosis/ICD-10 Coding for Lower Back Injury

ICD-10 Coding for Lower Back Injury

S39.012A
M54.51

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

Also Known as:
Lumbar Injury
Lower Back Strain
Lumbago
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Key Information: ICD-10 Coding for Lower Back Injury

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

Use ICD-10 code S39.012A for strain of muscle, fascia and tendon of lower back, initial encounter, ensuring proper documentation in clinical notes.

Primary ICD-10-CM Codes

Strain of muscle, fascia and tendon of lower back, initial encounter

Billable Code
S39.012A
Billable

Diagnostic Criteria

clinical:
  • • Presence of acute pain and muscle tenderness
documentation:
  • • Detailed description of the injury mechanism

Applicable To

  • • Acute lower back strain
  • • Muscle tear in lower back

Important Notes

  • • Ensure documentation specifies the acute nature of the injury.

Vertebrogenic low back pain

Billable Code
M54.51
Billable

Diagnostic Criteria

clinical:
  • • MRI findings of Modic changes
  • • Chronicity of symptoms

Applicable To

  • • Chronic low back pain with vertebral origin

Important Notes

  • • Ensure MRI findings are documented to support vertebrogenic diagnosis.
Ancillary Codes

Additional codes that may be used with this diagnosis

M54.5

Low back pain

Use for documenting associated pain with the strain.

M51.06

Intervertebral disc disorders with myelopathy, lumbar region

Use when disc disorders are also present.

Frequently Asked Questions

What is the ICD-10 code for a lower back strain?

The ICD-10 code for a lower back strain is S39.012A, which is used for acute strains of the lower back muscles.

How do you code chronic lower back pain?

Chronic lower back pain without a specific injury is coded as M54.5, while vertebrogenic pain with MRI findings is coded as M54.51.

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