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ICD-10 Guide
ICD-10 CodesM48.06

M48.06

Billable

Spinal stenosis, lumbar region

BILLABLE STATUSYes
IMPLEMENTATION DATEOctober 1, 2015
LAST UPDATED09/17/2025

Code Description

ICD-10 M48.06 is a billable code used to indicate a diagnosis of spinal stenosis, lumbar region.

Key Diagnostic Point:

Spinal stenosis in the lumbar region refers to the narrowing of the spinal canal in the lower back, which can lead to compression of the spinal cord and nerve roots. This condition is often caused by degenerative changes associated with aging, such as osteoarthritis, disc herniation, or thickening of ligaments. Patients may experience symptoms such as lower back pain, leg pain (sciatica), numbness, and weakness, particularly when standing or walking. The condition can significantly impact mobility and quality of life. Diagnosis typically involves a combination of clinical evaluation, imaging studies like MRI or CT scans, and neurological assessments. Treatment options range from conservative management, including physical therapy and pain management, to surgical interventions like laminectomy or spinal fusion, depending on the severity of symptoms and the degree of stenosis.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Differentiating between types of spinal stenosis (congenital vs. acquired)
  • Identifying associated conditions such as spondylolisthesis or herniated discs
  • Variability in symptom presentation among patients
  • Need for precise documentation of imaging findings

Audit Risk Factors

  • Inadequate documentation of symptoms and their impact on daily activities
  • Failure to document imaging results that support the diagnosis
  • Misclassification of stenosis type (e.g., congenital vs. degenerative)
  • Lack of clarity in treatment plans and follow-up care

Specialty Focus

Medical Specialties

Orthopedic Surgery

Documentation Requirements

Detailed operative reports, imaging studies, and pre-operative assessments.

Common Clinical Scenarios

Surgical intervention for severe lumbar spinal stenosis with radiculopathy.

Billing Considerations

Ensure that all surgical indications and outcomes are clearly documented.

Neurology

Documentation Requirements

Comprehensive neurological evaluations and imaging interpretations.

Common Clinical Scenarios

Management of chronic pain and neurological deficits due to lumbar stenosis.

Billing Considerations

Documenting the neurological examination findings is crucial for accurate coding.

Coding Guidelines

Inclusion Criteria

Use M48.06 When
  • According to ICD
  • 10 guidelines, M48
  • 06 should be used when the condition is specifically identified as lumbar spinal stenosis
  • It is important to document the severity of symptoms and any associated conditions

Exclusion Criteria

Do NOT use M48.06 When
  • Exclusion criteria include conditions that do not involve spinal stenosis

Related ICD-10 Codes

Related CPT Codes

63030CPT Code

Laminectomy, lumbar

Clinical Scenario

Used for surgical treatment of lumbar spinal stenosis.

Documentation Requirements

Operative report detailing the procedure and indications.

Specialty Considerations

Orthopedic surgeons must document the rationale for surgery.

ICD-10 Impact

Diagnostic & Documentation Impact

Enhanced Specificity

ICD-10 Improvements

The transition to ICD-10 has allowed for more specific coding of spinal conditions, including lumbar spinal stenosis. This specificity helps in better tracking of treatment outcomes and resource allocation.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of spinal conditions, including lumbar spinal stenosis. This specificity helps in better tracking of treatment outcomes and resource allocation.

Reimbursement & Billing Impact

The transition to ICD-10 has allowed for more specific coding of spinal conditions, including lumbar spinal stenosis. This specificity helps in better tracking of treatment outcomes and resource allocation.

Resources

Clinical References

  • •
    ICD-10-CM Official Guidelines for Coding and Reporting

Coding & Billing References

  • •
    ICD-10-CM Official Guidelines for Coding and Reporting

Frequently Asked Questions

What are the common symptoms of lumbar spinal stenosis?

Common symptoms include lower back pain, leg pain, numbness, and weakness, particularly when standing or walking.

How is lumbar spinal stenosis diagnosed?

Diagnosis is typically made through a combination of clinical evaluation and imaging studies such as MRI or CT scans.