A 46-year-old male with no known prior past medical history presents with lower back pain immediately after attempting to lift a heavy load from his SUV. He denies any falls, trauma, or any prior history of back pain. He reports the pain is in lumbar region and radiates down the right leg, it is worse with lumbar flexion or walking, and improved when laying or standing still. There is no urinary or bowel incontinence. He denies any history back surgeries, or known malignancies. Pt denies any history of intravenous drug abuse, alcohol or tobacco use.
Physical exam: mild discomfort. Normal appearance of back, with normal curvature. There is mild tenderness to palpation of paraspinal muscles R>L. No spinous process tenderness. Positive straight leg exam on the right side, negative on left. Neurologic exam is normal. Normal rectal tone. No advanced imaging.
Pain improved with muscle relaxants, ibuprofen, and the patient is discharged from the ED.
ICD 10 code: Lumbago with Sciatica, Right sided - M54.41
This is a subcategory of Dorsalgia(M54.*). M54.4- indicates lumbago with sciatica. Identifying as only sciatica(M54.3) or lower back pain(M54.5) would be inappropriate in this instance due to both having "Excludes 1" notation for situations with lower back pain/lumbago with sciatica(M54.4-). Laterality is also required for appropriate billable coding, making an M54.4 a non-billable code. Requirement is specified as: right(1), left(2), or unspecified(0). A broader billable code applicable would be Dorsalgia, unspecified (M54.9); although, this would be less specific than the prior coding. If any advanced imaging had been utilized and showed intervertebral disc pathology, a more appropriate billing code may have been M51.-(Thoracic, thoracolumbar, and lumbosacral intervertebral disc disorders).
For additional information on ICD-10 coding for emergency medicine, visit the ACEP Reimbursement page.