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v1.0.0
ICD-10 Guide
DiagnosesLumbosacral Strain

Lumbosacral Strain

ICD-10 Coding for Lumbosacral Strain(S39.012A, S39.012D, S39.012S)

PRIMARY SPECIALTYEmergency Medicine
COMPLEXITYHigh
LAST UPDATED09/15/2025
Sam Tuffun, PT, DPT
Physical Therapist | Medical Coding & Billing Contributor

Diagnosis Overview

What is Lumbosacral Strain?
Essential facts and insights about Lumbosacral Strain

Key Clinical Considerations:

  • Lower back pain, muscle spasms, limited range of motion
  • MRI or CT scan may show soft tissue injury; X-rays to rule out fractures
  • Tenderness in the lumbosacral region, muscle tightness, pain with movement

Clinical Information

Clinical Criteria & Documentation Requirements

  • Patient history of injury, description of pain, physical exam findings
  • Use of terms like 'strain', 'sprain', 'muscle injury'
  • Example: 'Patient presents with acute lumbosacral strain following lifting injury.'

Coding Guidelines

Usage Guidelines & Examples

  • Follow guidelines for acute vs. chronic conditions
  • Common errors include misclassifying the severity of the strain

Code Exclusions

Important Exclusions

  • Fractures of the lumbar spine, herniated discs
  • M54.5 - Low back pain as an alternative code

Related ICD-10 Codes

Primary Codes
S39.012A
Strain of muscle, fascia and tendon of lower back, initial encounter
Ancillary Codes
Z68.3_
Differential Codes
M54.5
M54.50
M54.59

Related CPT Codes

CPT codes will be available in a future update.

Specialty Focus

Primary Specialty

Emergency Medicine

Specialty Applications

  • Adults, athletes, individuals with physically demanding jobs
  • Emergency departments, urgent care centers

Coding Complexity

High Complexity

This diagnosis requires careful attention to:

  • Comprehensive clinical documentation
  • Accurate code selection based on clinical criteria
  • Proper exclusion considerations
  • Specialty-specific coding guidelines

Documentation

Documentation Templates

Billing Information

Billing Considerations

  • Ensure proper documentation for billing
  • Verify code specificity requirements
  • Check for any additional codes needed
  • Review payer-specific guidelines

Common Issues

  • Insufficient clinical documentation
  • Incorrect code selection
  • Missing supporting diagnoses
  • Timing and frequency documentation

Frequently Asked Questions

Documentation requirements?

Include mechanism of injury, pain severity, and physical exam findings.

Billing considerations?

Ensure accurate coding to reflect the severity and treatment provided.