Radiculopathy, lumbar region
ICD-10 M54.16 is a billable code used to indicate a diagnosis of radiculopathy, lumbar region.
Radiculopathy in the lumbar region refers to a condition where nerve roots in the lower back are compressed or irritated, leading to pain, weakness, or numbness that radiates down the leg. This condition is often associated with herniated discs, spinal stenosis, or degenerative disc disease. Patients typically present with symptoms such as lower back pain (dorsalgia), sciatica, and may experience difficulty in movement or sensation changes in the lower extremities. The pain can be sharp, burning, or tingling and may worsen with certain activities or positions. Conservative management often includes physical therapy, pain management with medications, and lifestyle modifications. In cases where conservative treatment fails or if there is significant neurological impairment, surgical intervention may be considered to relieve pressure on the affected nerve roots. Accurate diagnosis and management are crucial to prevent chronic pain and disability.
Detailed history of present illness, physical examination findings, imaging results, and treatment plans.
Patients presenting with acute or chronic lower back pain, often with neurological symptoms.
Ensure clear documentation of conservative management efforts before considering surgical options.
Neurological examination findings, imaging studies, and response to treatments.
Patients with radicular pain and neurological deficits requiring further evaluation.
Documenting the neurological examination findings is critical for accurate coding.
Used in surgical treatment of lumbar radiculopathy.
Operative report detailing the procedure and indication.
Orthopedic or neurosurgical documentation must support the need for surgery.
Radiculopathy refers to nerve root compression leading to pain and neurological symptoms, while sciatica specifically describes pain that radiates along the path of the sciatic nerve, often due to lumbar radiculopathy.
