From the Research
The ICD-10 code for back pain with left side radiculopathy is M54.16 (Radiculopathy, lumbar region) or M54.17 (Radiculopathy, lumbosacral region), depending on the exact location of the condition.
Key Considerations
- The code selection should be based on the specific region of the spine affected, with the lumbar and lumbosacral regions being most common for radiculopathy symptoms that affect the lower extremities 1.
- When documenting this condition, it's essential to note any specific findings from physical examination or imaging studies that support the diagnosis of radiculopathy, such as positive straight leg raise test, diminished reflexes, sensory changes, or MRI findings showing nerve compression.
- The use of epidural injections for lumbar radiculopathy has been supported by multiple systematic reviews and meta-analyses, including a 2021 study published in the Pain Physician journal, which found significant improvement in pain relief and functional status with epidural injections utilizing fluoroscopic guidance 1.
Coding Guidelines
- M54.16 is used for radiculopathy in the lumbar region, while M54.17 is used for radiculopathy in the lumbosacral region.
- If the radiculopathy is specifically in the thoracic region, the code would be M54.15.
- It's crucial to choose the correct code to ensure appropriate treatment planning and insurance reimbursement for this painful condition.
Clinical Evidence
- A 2020 study published in the Journal of Clinical Orthopaedics and Trauma found that transforaminal epidural injections or selective nerve root blocks are effective in managing lumbar radicular syndrome, with a success rate of 76-88% 2.
- A 2015 study published in the Annals of Internal Medicine found that epidural corticosteroid injections are associated with immediate reductions in pain and function, but the benefits are small and not sustained 3.