Dorsalgia, unspecified
ICD-10 M54.9 is a billable code used to indicate a diagnosis of dorsalgia, unspecified.
Dorsalgia, or back pain, is a common condition characterized by discomfort or pain in the back region, which can arise from various causes including muscle strain, ligament sprain, herniated discs, or degenerative disc disease. The term 'unspecified' indicates that the exact cause of the dorsalgia has not been determined, making it a broad category for back pain that does not fit into more specific diagnoses. Patients may present with acute or chronic pain, which can be localized or radiate to other areas, such as the legs, potentially indicating sciatica. Treatment options vary widely and may include conservative management such as physical therapy, medications (NSAIDs, muscle relaxants), and lifestyle modifications. In cases where conservative measures fail, surgical interventions may be considered, particularly if there is significant nerve compression or structural abnormalities. Accurate coding is essential for appropriate treatment planning and reimbursement, as dorsalgia can significantly impact a patient's quality of life and functional abilities.
Detailed patient history, physical examination findings, and treatment plans must be documented.
Patients presenting with acute back pain after lifting heavy objects or chronic pain due to degenerative changes.
Ensure to document any red flags that may indicate serious underlying conditions.
Imaging results, surgical notes, and follow-up care must be clearly documented.
Patients with persistent back pain requiring surgical evaluation or intervention.
Document the rationale for surgical intervention if conservative management fails.
Used in conjunction with M54.9 for physical therapy treatment.
Documentation of the patient's condition and treatment goals.
Physical therapists should document progress and response to therapy.
M54.9 should be used when the specific cause of dorsalgia is not documented, and it is essential to ensure that all relevant clinical information is captured to support its use.
