Correctly Identify Low Back Pain AAPC Knowledge Center

icd 10 low back pain

You won’t always find a distinction between acute and chronic pain in the patient record, but the provider should document as much detail as possible because it always leads to the ability to code to the highest specificity. Pain typically falls under acute or chronic, explains Maureen Leahey, CHC, CPC, primary care coding team leader with Sentara Healthcare in Norfolk, Virginia. With acute diagnoses, the cause is typically known, such as a car accident.

The provider documents persistent low back pain that has been ongoing for several months with failed management. This code describes pain that isn’t directly on the spine but, rather, in the area surrounding the low back. The code may be appropriate to report a symptom of a more specific illness that has yet to be determined. Full details of the current ICD-10 diagnoses codes can be downloaded on the Centers article source for Medicare & Medicaid Services website using the 2022 Code Tables, Tabular and Index link toward the bottom of the page. Coding low back pain can be a challenge because you need a lot of information to select the most appropriate diagnosis code. Along with a complete medical history and physical exam, the provider can use neurological tests and imaging to rule out, identify, or confirm specific causes.

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You query the provider and learn that the patient has low back pain (LBP). Relief for LBP may come from plenty of rest, pain relievers, cortisone injections, therapy, hands-on treatment like chiropractic care, or even surgery to heal certain conditions and back injuries. Your Academy continues to advocate for a permanent solution to the conversion factor cut while maintaining the important payment increases to office and outpatient evaluation and management services. As a person ages, the pain can develop over time or come on suddenly by lifting something that may be too heavy or by the force of an accident.

A demanding workout can also cause LBP if the individual is not physically prepared. The provider lists both low back strain and back pain separately in the Assessment and Plan. This type of LBP would need to be verified by more advanced testing, such as magnetic resonance imaging (MRI), before you could report this code. This site is dedicated exclusively to helping you look up ICD-10 codes, quickly access the codes you use most, and become more comfortable with the new code set in general. The pain can vary from mild to severe or a dull, continuous ache to unanticipated sharp or shooting pain. Pain can make sleeping, walking, or activities of daily living (ADL) challenging or unfeasible.

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There are certain occasions when a code from the G89 category will be your first-listed diagnosis. Examples of when this would be appropriate include the implantation of a neurostimulator or a spinal epidural injection to manage pain from a herniated disc causing radiculopathy. It would not be appropriate to assign a G89 code when an encounter is to treat the cause of the patient’s chronic pain, such as a patient undergoing lumbar fusion to treat degenerative disc disease.

For these new additions, the more details, the better for more accurate coding and fewer reasons for denial. If the provider has images confirming degenerative disc disease, spinal stenosis, or a herniated disc, for example, these would be better [diagnosis] options to use since the condition would try this be the cause of the pain, says Leahey. Per the Excludes1 note, some lumbago is classified elsewhere, Moore points out. Lumbago is a general term often used for pain in the lower back, so you should pay attention to the patient record carefully, and query the provider if questions arise.

icd 10 low back pain

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When the documentation is not clear enough for correct coding, it’s time to query the provider. However, it’s important that your queries do not sway a provider to document a certain additional reading way. An Excludes2 note indicates that the excluded condition is not part of the condition represented by the code; however, the patient may have both conditions at the same time.

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