Sciatica, unspecified side
ICD-10 M54.30 is a billable code used to indicate a diagnosis of sciatica, unspecified side.
Sciatica refers to pain that radiates along the path of the sciatic nerve, which branches from the lower back through the hips and buttocks and down each leg. The condition is often characterized by pain that can vary in intensity, ranging from mild discomfort to severe pain that can limit mobility. Sciatica is typically caused by compression of the nerve roots in the lumbar spine due to herniated discs, spinal stenosis, or degenerative disc disease. Patients may also experience symptoms such as numbness, tingling, or weakness in the affected leg. The term 'unspecified side' indicates that the documentation does not specify whether the pain is on the left or right side, which can complicate treatment and management strategies. Treatment options for sciatica can be conservative, including physical therapy, medications, and lifestyle modifications, or surgical, such as discectomy or laminectomy, depending on the severity and underlying cause of the nerve compression. Accurate coding is essential for appropriate reimbursement and to ensure that patients receive the correct level of care.
Detailed history of present illness, physical examination findings, imaging results, and treatment plans.
Patients presenting with lower back pain radiating to the leg, often after an injury or with chronic conditions.
Ensure clear documentation of the side affected and any imaging studies performed.
Comprehensive assessment of functional limitations, treatment goals, and progress notes.
Patients undergoing rehabilitation for sciatica-related pain and functional impairment.
Document the patient's response to conservative treatments and any referrals for surgical evaluation.
Used in conjunction with M54.30 for physical therapy sessions.
Document the type and duration of exercises performed.
Physical therapists should ensure that the treatment plan aligns with the diagnosis.
Use M54.30 when the documentation does not specify the side affected by sciatica. If the side is known, use M54.31 for left side or M54.32 for right side.
