ICD-10 Guide

M51.379

Name: ICD-10-CM Medical Diagnosis Codes
Creator: Centers for Medicare & Medicaid Services
License: https://www.cms.gov/medicare/coding/icd10

Billable

Other intervertebral disc degeneration, lumbosacral region without mention of lumbar back pain or lower extremity pain

BILLABLE STATUSYes

IMPLEMENTATION DATEOctober 1, 2015

LAST UPDATED08/28/2025

Code Description

ICD-10 M51.379 is a billable code used to indicate a diagnosis of other intervertebral disc degeneration, lumbosacral region without mention of lumbar back pain or lower extremity pain.

Key Diagnostic Point:

Other intervertebral disc degeneration, lumbosacral region without mention of lumbar back pain or lower extremity pain

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

### ICD-10 Code Analysis: M51.379 **1) Complexity Rating: Medium** The complexity of ICD-10 code M51.379 is rated as medium due to the specific nature of the diagnosis, which requires a clear understanding of the patient's condition and the absence of associated symptoms like lumbar back pain or lower extremity pain. This necessitates thorough documentation to support the diagnosis. --- **2) Documentation Requirements** - **Clinical Documentation**: The medical record must clearly indicate the diagnosis of intervertebral disc degeneration in the lumbosacral region. - **Symptomatology**: Documentation should explicitly state the absence of lumbar back pain and lower extremity pain to justify the use of this specific code. - **Diagnostic Imaging**: Any imaging studies (e.g., MRI, CT scans) that support the diagnosis should be included in the documentation. - **Treatment Plan**: A detailed treatment plan should be documented, including any conservative management or referrals to specialists. --- **3) Clinical Considerations** - **Patient History**: A comprehensive patient history should be taken to rule out other causes of back pain or neurological symptoms. - **Physical Examination**: A thorough physical examination is essential to assess the extent of degeneration and to rule out other conditions. - **Differential Diagnosis**: Consideration of other potential diagnoses that may present similarly, such as herniated discs or spinal stenosis, is crucial. - **Follow-Up**: Regular follow-up appointments should be documented to monitor the progression of the condition and the effectiveness of the treatment plan. --- **4) Audit Risk Factors** - **Inadequate Documentation**: Lack of clear documentation regarding the absence of pain symptoms can lead to audit risks and potential denials. - **Misuse of Code**: Incorrectly coding for conditions that include pain or other symptoms can result in compliance issues. - **Lack of Supporting Evidence**: Failure to provide supporting diagnostic imaging or clinical findings may increase the risk of audits. - **Inconsistent Coding**: Variability in coding practices among providers can lead to discrepancies and increased scrutiny during audits. --- **5) Coding Best Practices** - **Specificity**: Always use the most specific code available. In this case, M51.379 is appropriate for intervertebral disc degeneration without pain. - **Comprehensive Documentation**: Ensure that all relevant clinical information is documented, including the absence of pain and any diagnostic tests performed. - **Regular Training**: Keep coding staff updated on the latest coding guidelines and changes in ICD-10 to minimize errors. - **Utilize Coding Software**: Employ coding software that can assist in verifying the accuracy and specificity of codes used. - **Peer Review**: Implement a peer review process for coding to ensure accuracy and compliance with coding standards. By adhering to these guidelines, healthcare professionals can ensure accurate coding, reduce audit risks, and improve the quality of patient care.

Specialty Focus

Medical Specialties

### Medical Specialties Related to ICD-10 Code M51.379 **ICD-10 Code:** M51.379 **Description:** Other intervertebral disc degeneration, lumbosacral region without mention of lumbar back pain or lower extremity pain. #### 1. Primary Specialty - **Orthopedic Surgery (40%)** - Orthopedic surgeons often manage conditions related to intervertebral disc degeneration, particularly in the lumbosacral region. They may perform surgical interventions such as discectomy or spinal fusion when conservative treatments fail. #### 2. Secondary Specialties - **Neurology (25%)** - Neurologists evaluate and treat neurological symptoms that may arise from intervertebral disc degeneration, including nerve root compression and associated neurological deficits. - **Physical Medicine and Rehabilitation (PM&R) (20%)** - PM&R specialists focus on non-surgical management, including physical therapy, pain management, and rehabilitation strategies to improve function and quality of life. - **Rheumatology (10%)** - Rheumatologists may be involved in cases where intervertebral disc degeneration is associated with inflammatory or autoimmune conditions affecting the spine. - **Pain Management (5%)** - Pain management specialists provide interventions such as epidural steroid injections or other pain relief techniques for patients experiencing discomfort due to disc degeneration. #### 3. Documentation Requirements - **Clinical History:** - Detailed patient history including onset, duration, and progression of symptoms. - Previous treatments and their outcomes. - **Physical Examination:** - Neurological examination findings, including reflexes, strength, and sensory deficits. - **Imaging Studies:** - MRI or CT scans to confirm the diagnosis of intervertebral disc degeneration. - **Assessment of Functional Limitations:** - Documentation of how the condition affects daily activities and quality of life. - **Treatment Plan:** - Clear outline of the proposed management strategy, including conservative measures or surgical options. #### 4. Clinical Scenarios - **Scenario 1:** - A 55-year-old male presents with chronic lower back stiffness and mild discomfort but no radicular pain. MRI reveals degenerative changes in the L4-L5 disc. The orthopedic surgeon recommends a conservative management plan including physical therapy and lifestyle modifications. - **Scenario 2:** - A 62-year-old female reports intermittent lower back discomfort without radiation to the legs. Neurological evaluation shows no deficits. The PM&R specialist prescribes a tailored rehabilitation program focusing on core strengthening and flexibility exercises. - **Scenario 3:** - A 48-year-old male with a history of obesity and sedentary lifestyle presents with lumbar stiffness. Imaging shows significant disc degeneration. The pain management specialist discusses weight loss strategies and offers an epidural steroid injection for symptomatic relief. #### 5. Specialty Considerations - **Orthopedic Surgery:** - Surgeons must consider the patient's overall health, comorbidities, and the potential for surgical complications. A multidisciplinary approach is often beneficial. - **Neurology:** - Neurologists should assess for any signs of nerve root involvement and consider differential diagnoses that may mimic disc degeneration. - **PM&R:** - Rehabilitation specialists should focus on functional outcomes and patient education regarding self-management strategies. - **Rheumatology:** - In cases where degeneration is secondary to inflammatory conditions, rheumatologists must manage the underlying disease to improve spinal health. - **Pain Management:** - Pain specialists should evaluate the appropriateness of interventional procedures based on the patient's specific pain profile and response to conservative treatments. ### Conclusion Understanding the implications of ICD-10 code M51.379 is crucial for healthcare professionals across various specialties. Proper documentation, a multidisciplinary approach, and tailored treatment plans are essential for optimal patient outcomes in managing intervertebral disc degeneration in the lumbosacral region.

Coding Guidelines

Inclusion Criteria

Use M51.379 When

10 Code: M51
Other Intervertebral Disc Degeneration, Lumbosacral Region Without Mention of Lumbar Back Pain or Lower Extremity Pain
1) Inclusion Criteria
This code is applicable for patients diagnosed with degeneration of intervertebral discs in the lumbosacral region that does not present with lumbar back pain or pain radiating to the lower extremities
Conditions that may be coded under M51
379 include:
Degenerative disc disease of the lumbosacral spine without associated pain
Disc degeneration noted on imaging studies without clinical symptoms of pain

Exclusion Criteria

Do NOT use M51.379 When

2) Exclusion Notes
Exclusions:

Related CPT Codes

### CPT Codes for ICD-10 M51.379: Other Intervertebral Disc Degeneration, Lumbosacral Region #### 1. Lab/Diagnostic Procedures For the diagnosis of intervertebral disc degeneration, the following CPT codes may be applicable: - **72148**: MRI, lumbar spine, without contrast material. - **72149**: MRI, lumbar spine, with contrast material. - **72150**: MRI, lumbar spine, without and with contrast material. - **72020**: X-ray, spine, lumbosacral, 2 or 3 views. - **72220**: CT, lumbar spine, without contrast material. - **72221**: CT, lumbar spine, with contrast material. #### 2. Treatment Procedures Treatment options may include both conservative and interventional procedures. Relevant CPT codes include: - **97001**: Physical therapy evaluation. - **97002**: Physical therapy re-evaluation. - **97110**: Therapeutic exercises to develop strength and endurance, range of motion, and flexibility. - **97112**: Neuromuscular re-education of movement, balance, coordination, kinesthetic sense, posture, and proprioception. - **20610**: Arthrocentesis, aspiration, and/or injection into a major joint or bursa (if applicable). - **62287**: Injection procedure for the lumbar spine (e.g., epidural steroid injection). - **63030**: Laminectomy, facetectomy, and/or foraminotomy, lumbar (if surgical intervention is necessary). #### 3. Follow-Up Codes Follow-up visits may be coded using: - **99211-99215**: Established patient office or other outpatient visit codes, depending on the complexity of the visit. - **99354**: Prolonged service in the office or other outpatient setting (if applicable). #### 4. Reimbursement Ranges Reimbursement rates can vary based on geographic location, payer contracts, and specific circumstances. However, general ranges for the listed codes are as follows: - **MRI Codes (72148, 72149, 72150)**: $400 - $1,200 - **X-ray Code (72020)**: $50 - $150 - **CT Codes (72220, 72221)**: $500 - $1,500 - **Physical Therapy Codes (97001, 97002, 97110, 97112)**: $30 - $150 per session - **Injection Codes (20610, 62287)**: $150 - $600 - **Surgical Codes (63030)**: $1,500 - $5,000 #### 5. Billing Notes - Ensure that documentation supports the medical necessity for all procedures performed. - Use modifiers as appropriate (e.g., modifier 50 for bilateral procedures). - Verify insurance coverage for specific diagnostic imaging and treatment modalities. - Follow payer-specific guidelines for coding and billing to avoid denials. - Consider the use of appropriate modifiers for any follow-up or prolonged services. ### Conclusion When coding for ICD-10 M51.379, it is essential to select the appropriate CPT codes based on the diagnostic and treatment procedures performed. Accurate documentation and adherence to coding guidelines will facilitate proper reimbursement and compliance with payer requirements. Always consult the latest coding manuals and payer policies for updates and changes.

ICD-10 Impact

Diagnostic & Documentation Impact

Enhanced Specificity

ICD-10 Improvements

Impact of ICD-10 Code M51.379: Other Intervertebral Disc Degeneration, Lumbosacral Region Without Mention of Lumbar Back Pain or Lower Extremity Pain

1. Clinical Specificity vs. ICD-9

The transition from ICD-9 to ICD-10 significantly enhances clinical specificity. The ICD-9 coding system had limited granularity, often requiring the use of unspecified codes that did not accurately reflect the patient's condition. For example, in ICD-9, intervertebral disc degeneration might have been coded under a more generalized code (e.g., 722.10 for disc degeneration).

ICD-9 vs ICD-10

Impact of ICD-10 Code M51.379: Other Intervertebral Disc Degeneration, Lumbosacral Region Without Mention of Lumbar Back Pain or Lower Extremity Pain 1. Clinical Specificity vs. ICD-9 The transition from ICD-9 to ICD-10 significantly enhances clinical specificity. The ICD-9 coding system had limited granularity, often requiring the use of unspecified codes that did not accurately reflect the patient's condition. For example, in ICD-9, intervertebral disc degeneration might have been coded under a more generalized code (e.g., 722.10 for disc degeneration). In contrast, ICD-10 code M51.379 provides a more precise classification of intervertebral disc degeneration in the lumbosacral region, explicitly indicating that there is no associated lumbar back pain or lower extremity pain. This specificity allows healthcare providers to better document the patient's condition, leading to improved clinical decision-making and tailored treatment plans. 2. Quality Measures The specificity of ICD-10 codes like M51.379 contributes to enhanced quality measures in healthcare. Quality measures...

Reimbursement & Billing Impact

reimbursement.

Resources

Clinical References

No clinical reference resources available for this code.

Coding & Billing References

No coding and billing reference resources available for this code.

Frequently Asked Questions

# FAQs for ICD-10 Code M51.379: Other Intervertebral Disc Degeneration, Lumbosacral Region Without Mention of Lumbar Back Pain or Lower Extremity Pain ### Q1: Is M51.379 a billable code? **A1:** Yes, M51.379 is a billable code. It is classified as a specific diagnosis that can be used for billing purposes when the criteria for this code are met. Ensure that the documentation supports the diagnosis of intervertebral disc degeneration in the lumbosacral region without associated lumbar back pain or lower extremity pain. ### Q2: What are the documentation requirements for using M51.379? **A2:** To appropriately use M51.379, the following documentation is required: - A clear diagnosis of intervertebral disc degeneration in the lumbosacral region. - Explicit notation that there is no mention of lumbar back pain or lower extremity pain. - Relevant clinical findings, imaging results, and any treatment plans that support the diagnosis. - Documentation should be comprehensive and reflect the patient's history and physical examination. ### Q3: When should M51.379 be used versus alternative codes? **A3:** M51.379 should be used when: - The patient has intervertebral disc degeneration specifically in the lumbosacral region. - There is no documentation of lumbar back pain or lower extremity pain associated with the condition. Alternative codes may include: - M51.36 (Other intervertebral disc degeneration, lumbosacral region with lumbar back pain) if lumbar pain is present. - M54.5 (Low back pain) if the primary complaint is low back pain without specific mention of disc degeneration. ### Q4: What are common scenarios for using M51.379? **A4:** Common scenarios for using M51.379 include: - A patient presenting for routine follow-up after imaging reveals intervertebral disc degeneration in the lumbosacral area, but the patient reports no pain. - A patient undergoing evaluation for unrelated conditions where incidental findings show disc degeneration without associated symptoms. - Documentation from a physical examination indicating degenerative changes in the lumbosacral region without any pain complaints. ### Q5: What resources can healthcare professionals refer to for more information on M51.379? **A5:** Healthcare professionals can refer to the following resources: - **ICD-10-CM Official Guidelines for Coding and Reporting**: This document provides comprehensive guidelines on the use of ICD-10 codes. - **American Academy of Professional Coders (AAPC)**: Offers coding resources, webinars, and training materials. - **Centers for Medicare & Medicaid Services (CMS)**: Provides updates and resources related to coding and billing practices. - **National Center for Health Statistics (NCHS)**: Offers detailed information on ICD-10-CM codes and their definitions. For further assistance, coding professionals may also consult with certified medical coders or coding specialists within their organization.

M51.379

Code Description

Key Diagnostic Point:

Code Complexity Analysis

Complexity Rating: Medium

Specialty Focus

Medical Specialties

Coding Guidelines

Inclusion Criteria

Exclusion Criteria

Related ICD-10 Codes

Related CPT Codes

ICD-10 Impact

Diagnostic & Documentation Impact

ICD-10 Improvements

ICD-9 vs ICD-10

Reimbursement & Billing Impact

Resources

Clinical References

Coding & Billing References

Frequently Asked Questions

M51.379

Code Description

Key Diagnostic Point:

Code Complexity Analysis

Complexity Rating: Medium

Specialty Focus

Medical Specialties

Coding Guidelines

Inclusion Criteria

Exclusion Criteria

Related ICD-10 Codes

Related CPT Codes

ICD-10 Impact

Diagnostic & Documentation Impact

ICD-10 Improvements

ICD-9 vs ICD-10

Reimbursement & Billing Impact

Resources

Clinical References

Coding & Billing References

Frequently Asked Questions