What is the ICD (International Classification of Diseases) code for left gluteal pain with lumbar radiculopathy?

From the Research

The ICD-10 code for left gluteal pain with radiculopathy is M54.17 (Radiculopathy, lumbosacral region). This code specifically captures the radicular pain originating from the lumbosacral spine and radiating to the gluteal region on the left side. When documenting this condition, it's essential to note any specific nerve root involvement if known (such as L5 or S1) and to document objective findings from physical examination that support the diagnosis, such as positive straight leg raise test, diminished reflexes, sensory changes, or motor weakness. Additional codes may be needed if there is a known underlying cause for the radiculopathy, such as disc herniation (M51.16 for lumbar intervertebral disc disorder with radiculopathy) or spinal stenosis (M48.06 for lumbar spinal stenosis). The laterality (left side) should be clearly documented in the medical record to support the specificity of the coding, though the code itself does not distinguish laterality for radiculopathy.

Key Considerations

• The diagnosis of radiculopathy should be based on a combination of clinical presentation, physical examination, and diagnostic imaging studies, as discussed in 1.
• The presence of gluteal trigger points is common in patients with lumbosacral radiculopathy, as shown in 2, and may be an important consideration in the management of these patients.
• Conservative management of lumbar radiculopathy should be tailored to the stage of the disorder, as outlined in 3, and may include a range of interventions such as physical therapy, pain education, and epidural injections.
• Epidural injections with or without steroids can be an effective treatment for radiculopathy, as demonstrated in 4, and may be considered as part of a comprehensive management plan.
• The differential diagnosis of buttock pain should include both radiculopathy and referred pain, as discussed in 5, and a selective nerve root block may be a useful diagnostic and therapeutic tool in these cases.

Coding and Documentation

• The ICD-10 code M54.17 should be used to capture the diagnosis of radiculopathy, lumbosacral region.
• Additional codes may be needed to capture underlying causes of radiculopathy, such as disc herniation or spinal stenosis.
• The laterality of the condition (left side) should be clearly documented in the medical record to support the specificity of the coding.