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v1.0.0
ICD-10 Guide
DiagnosesBilateral Lower Extremity Radiculopathy

Bilateral Lower Extremity Radiculopathy

ICD-10 Coding for Bilateral Lower Extremity Radiculopathy(M54.16)

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

Diagnosis Overview

What is Bilateral Lower Extremity Radiculopathy?
Essential facts and insights about Bilateral Lower Extremity Radiculopathy

Key Clinical Considerations:

  • Bilateral lower extremity pain, numbness, or weakness
  • Positive straight leg raise test
  • MRI or CT findings of lumbar disc herniation or spinal stenosis

Clinical Information

Clinical Criteria & Documentation Requirements

  • Patient history including onset and duration of symptoms
  • Neurological examination results
  • Imaging study reports

Coding Guidelines

Usage Guidelines & Examples

  • Follow guidelines for bilateral coding; avoid unbundling services.
  • Common errors include incorrect laterality or unspecified codes.

Code Exclusions

Important Exclusions

  • Unilateral radiculopathy, peripheral neuropathy
  • M54.15 (Radiculopathy, thoracic region)

Related ICD-10 Codes

Primary Codes
M54.16
Radiculopathy, lumbar region
M54.17
Radiculopathy, lumbosacral region
Ancillary Codes
M48.06
M54.16
if spinal stenosis is the underlying cause.
M51.36
M54.16
when disc degeneration is the underlying cause.
Differential Codes
M54.5
M54.5
only if radiculopathy is not confirmed.
M54.3x

Related CPT Codes

CPT codes will be available in a future update.

Specialty Focus

Primary Specialty

Neurology

Specialty Applications

  • Adults with lumbar spine issues, patients with chronic pain syndromes
  • Neurology clinics, pain management 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 detailed patient history, physical exam findings, and imaging results.

Billing considerations?

Ensure accurate coding to reflect the severity and location of radiculopathy.