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ICD-10 Guide
DiagnosesRight Lower Extremity Lumbar Radiculopathy

Right Lower Extremity Lumbar Radiculopathy

ICD-10 Coding for Right Lower Extremity Lumbar Radiculopathy(M54.16, M54.31, M51.16)

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

Diagnosis Overview

What is Right Lower Extremity Lumbar Radiculopathy?
Essential facts and insights about Right Lower Extremity Lumbar Radiculopathy

Key Clinical Considerations:

  • Unilateral pain radiating from the lumbar region to the right lower extremity
  • Numbness or tingling in the right leg or foot
  • Weakness in the right leg muscles
  • Positive straight leg raise test
  • Reflex changes in the right lower extremity

Clinical Information

Clinical Criteria & Documentation Requirements

  • Patient history including onset, duration, and nature of symptoms
  • Results of neurological examination and any imaging studies
  • Specific mention of radicular symptoms and affected nerve root

Coding Guidelines

Usage Guidelines & Examples

  • Follow guidelines for coding radiculopathy based on the affected side and level of involvement.
  • Common errors include misidentifying the side of radiculopathy or using non-specific codes.

Code Exclusions

Important Exclusions

  • Cervical radiculopathy
  • Peripheral neuropathy
  • M54.15 (Radiculopathy, lumbar region, left side)

Related ICD-10 Codes

Primary Codes
M54.16
Radiculopathy, lumbar region, right side
Ancillary Codes
G89.29
Differential Codes
M54.31
M54.16

Related CPT Codes

CPT codes will be available in a future update.

Specialty Focus

Primary Specialty

Orthopedics

Specialty Applications

  • Adults experiencing lower back pain with radicular symptoms
  • Orthopedic clinics and pain management settings

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

What are the documentation requirements?

Document the patient's symptoms, physical exam findings, and any imaging results.

What are the billing considerations?

Ensure accurate coding to reflect the specific diagnosis and any associated procedures.