Lumbago with sciatica, unspecified side
ICD-10 M54.40 is a billable code used to indicate a diagnosis of lumbago with sciatica, unspecified side.
Lumbago with sciatica, unspecified side (M54.40) refers to a condition characterized by lower back pain (lumbago) accompanied by pain radiating down the leg(s) due to irritation or compression of the sciatic nerve. This condition can arise from various underlying causes, including herniated discs, spinal stenosis, or degenerative disc disease. Patients often present with symptoms such as sharp or shooting pain, numbness, or weakness in the affected leg, which may worsen with prolonged sitting or standing. The term 'unspecified side' indicates that the documentation does not specify whether the symptoms are unilateral or bilateral, which can complicate treatment planning. Management typically involves conservative approaches such as physical therapy, pain management, and lifestyle modifications. In more severe cases, surgical interventions like discectomy or laminectomy may be considered. Accurate coding is essential for proper reimbursement and to reflect the severity of the patient's condition.
Detailed history of present illness, physical examination findings, imaging results, and treatment plans.
Patients presenting with acute or chronic lower back pain with associated leg pain.
Ensure clear documentation of the side affected if known, and the rationale for any surgical interventions.
Comprehensive assessment of functional limitations, treatment goals, and progress notes.
Patients undergoing rehabilitation for sciatica-related pain and mobility issues.
Document the effectiveness of conservative treatments and any referrals for surgical evaluation.
Used for patients undergoing physical therapy for sciatica.
Documentation of the treatment plan and progress notes.
Physical therapists should document specific exercises and patient responses.
Surgical intervention for severe cases of sciatica.
Pre-operative evaluations and post-operative follow-up notes.
Surgeons must document the rationale for surgery and any complications.
M54.40 is used when the side of sciatica is unspecified, while M54.41 is used when sciatica is present on the right side. Accurate coding requires documentation of the side affected.
