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Home/Diagnosis/ICD-10 Coding for Lumbosacral Strain

ICD-10 Coding for Lumbosacral Strain

S39.012A
S39.012D
S39.012S

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

Also Known as:
Lower Back Strain
Lumbosacral Muscle Strain
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Key Information: ICD-10 Coding for Lumbosacral Strain

Essential facts and insights about ICD-10 Coding for Lumbosacral Strain

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 muscle tenderness and pain with movement
documentation:
  • • Documentation must specify 'strain' and mechanism of injury

Applicable To

  • • Acute lumbosacral strain

Important Notes

  • • Ensure documentation specifies 'strain' to avoid confusion with non-specific back pain.

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

Billable Code
S39.012D
Billable

Applicable To

  • • Follow-up for lumbosacral strain

Important Notes

  • • Ensure follow-up documentation reflects ongoing treatment for strain.

Strain of muscle, fascia and tendon of lower back, sequela

Billable Code
S39.012S
Billable

Applicable To

  • • Chronic pain post-strain

Important Notes

  • • Ensure documentation links current symptoms to past strain.
Ancillary Codes

Additional codes that may be used with this diagnosis

Z68.3_

BMI ≥40 if obesity contributes

Use when obesity is a contributing factor to the strain.

Frequently Asked Questions

What is the ICD-10 code for lumbosacral strain?

The ICD-10 code for lumbosacral strain is S39.012A for initial encounters, S39.012D for subsequent encounters, and S39.012S for sequela.

How do you differentiate between lumbosacral strain and low back pain in coding?

Lumbosacral strain (S39.012) is used when a specific injury is documented, while M54.5 is for non-specific low back pain without a confirmed strain.

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