Low back pain
ICD-10 M54.5 is a billable code used to indicate a diagnosis of low back pain.
Low back pain, or dorsalgia, is a common condition characterized by discomfort or pain in the lower back region. It can arise from various causes, including muscle strain, ligament sprain, herniated discs, degenerative disc disease, or spinal stenosis. The pain may be acute, lasting less than three months, or chronic, persisting for more than three months. Patients may experience localized pain, radiating pain, or sciatica, which is characterized by pain that travels down the leg due to nerve compression. Diagnosis typically involves a thorough history and physical examination, and may include imaging studies such as X-rays or MRIs to identify underlying structural issues. Treatment options vary widely and can include conservative management such as physical therapy, medications (NSAIDs, muscle relaxants), and lifestyle modifications, or surgical interventions like discectomy or spinal fusion in severe cases. The choice of management depends on the severity of symptoms, the underlying cause, and the patient's overall health status.
Detailed history of present illness, physical examination findings, imaging results, and treatment plan.
Patients presenting with acute low back pain after an injury, chronic low back pain with radiculopathy, or post-operative pain following spinal surgery.
Ensure documentation reflects the specific nature of the pain and any functional limitations.
Comprehensive assessment of functional status, pain levels, and response to previous treatments.
Patients undergoing rehabilitation for chronic low back pain, post-surgical recovery, or pain management.
Focus on documenting the impact of pain on daily activities and the effectiveness of rehabilitation interventions.
Used for patients undergoing physical therapy for low back pain.
Document the specific exercises performed and patient progress.
Physical therapists should ensure alignment with the diagnosis of low back pain.
Acute low back pain lasts less than three months and is often related to a specific injury or event, while chronic low back pain persists for more than three months and may have multiple underlying causes.
