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Home/Diagnosis/ICD-10 Coding for Spinal Pain

ICD-10 Coding for Spinal Pain

M54.5
G89.21
S39.012

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

Also Known as:
Back Pain
Lumbar Pain
Dorsalgia
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Key Information: ICD-10 Coding for Spinal Pain

Essential facts and insights about ICD-10 Coding for Spinal Pain

Use ICD-10 code M54.5 for low back pain, ensuring proper documentation in clinical notes.

Primary ICD-10-CM Codes

Low back pain

Non-Billable
M54.5
Non-Billable

Diagnostic Criteria

  • • Localized lumbar pain without radiation or specific etiology

Applicable To

  • • Lumbago
  • • Pain in lumbar region

Important Notes

  • • Ensure documentation specifies the absence of radiculopathy or other specific conditions.

Chronic pain due to trauma

Billable Code
G89.21
Billable

Diagnostic Criteria

  • • Documentation of chronicity and link to trauma or surgery
  • • Duration of pain greater than 3 months

Applicable To

  • • Chronic post-traumatic pain

Important Notes

  • • Sequence first if the encounter is primarily for pain management.

Strain of muscle, fascia and tendon of lower back

Non-Billable
S39.012
Non-Billable

Diagnostic Criteria

  • • Mechanism of injury documented (e.g., lifting)
  • • Acute onset with supportive imaging (e.g., MRI)

Applicable To

  • • Acute lower back strain

Important Notes

  • • Ensure documentation includes the mechanism of injury.
Ancillary Codes

Additional codes that may be used with this diagnosis

G89.21

Chronic pain due to trauma

Use when chronic pain is linked to a traumatic event or surgery.

M54.51

Vertebrogenic low back pain

Use to specify the site of chronic pain.

Frequently Asked Questions

What is the ICD-10 code for spinal pain?

The ICD-10 code for unspecified low back pain is M54.5. For chronic pain due to trauma, use G89.21.

How do you code chronic spinal pain?

Chronic spinal pain linked to trauma or surgery is coded as G89.21, with additional site-specific codes as needed.

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