Low back pain, unspecified
ICD-10 M54.50 is a billable code used to indicate a diagnosis of low back pain, unspecified.
Low back pain, classified under M54.50, refers to discomfort or pain localized in the lower back region without a specified cause. This condition is prevalent and can arise from various factors, including muscle strain, ligament sprain, herniated discs, or degenerative disc disease. Patients may experience symptoms ranging from mild discomfort to severe pain that can limit mobility and daily activities. The pain may be acute, lasting less than three months, or chronic, persisting for more than three months. Dorsalgia is a broader term that encompasses back pain, including low back pain. Sciatica, characterized by pain radiating along the sciatic nerve, may also be associated with low back pain but is not specifically indicated in this code. Management of low back pain can be conservative, involving physical therapy, medications, and lifestyle modifications, or surgical, such as discectomy or spinal fusion, depending on the underlying cause and severity of symptoms. Accurate coding is essential for appropriate treatment and reimbursement.
Detailed history of present illness, physical examination findings, and treatment plan.
Patients presenting with acute low back pain after lifting heavy objects or chronic pain due to degenerative changes.
Ensure documentation reflects the patient's functional status and response to conservative treatments.
Imaging results, surgical notes if applicable, and detailed descriptions of physical findings.
Patients with herniated discs or spinal stenosis requiring surgical intervention.
Document the rationale for surgical versus conservative management clearly.
Used for patients undergoing physical therapy for low back pain.
Documentation of the patient's functional limitations and therapy goals.
Physical therapists should document progress and response to treatment.
M54.50 should be used when the specific cause of low back pain is not documented or when the provider has not specified whether the pain is acute or chronic.
