Spinal stenosis, lumbosacral region
ICD-10 M48.07 is a billable code used to indicate a diagnosis of spinal stenosis, lumbosacral region.
Spinal stenosis in the lumbosacral region refers to the narrowing of the spinal canal in the lower back, which can lead to compression of the spinal cord and nerve roots. This condition often results from degenerative changes associated with aging, such as osteoarthritis, disc herniation, or thickening of ligaments. Patients may present with symptoms including lower back pain, numbness, tingling, and weakness in the legs, which can be exacerbated by prolonged standing or walking. The diagnosis is typically confirmed through imaging studies such as MRI or CT scans, which reveal the extent of the stenosis and any associated structural changes. Treatment options may range from conservative management, including physical therapy and pain management, to surgical interventions like laminectomy or spinal fusion, depending on the severity of symptoms and the degree of stenosis. Accurate coding is essential for appropriate reimbursement and to reflect the complexity of the patient's condition.
Detailed operative reports and pre-operative assessments are necessary.
Patients presenting with severe pain and neurological deficits requiring surgical intervention.
Ensure that all imaging studies and conservative treatments are documented to justify surgical necessity.
Comprehensive neurological evaluations and follow-up assessments are critical.
Patients with chronic pain and neurological symptoms requiring non-surgical management.
Documenting the patient's functional status and response to conservative treatments is essential for accurate coding.
Used for surgical treatment of lumbosacral spinal stenosis.
Operative report detailing the procedure and indications.
Orthopedic surgeons must document the severity of stenosis and any neurological deficits.
Common symptoms include lower back pain, leg pain, numbness, tingling, and weakness, particularly when standing or walking.
Diagnosis is typically made through a combination of clinical evaluation and imaging studies such as MRI or CT scans.
Treatment may include physical therapy, pain management, and in some cases, surgical interventions like laminectomy or spinal fusion.
