M54.5 - Low back pain (ICD-10)
ICD-10 code M54.5 - Low back pain. Classified under Other dorsopathies, this condition involves clinical findings relevant to diagnosis and documentation accuracy.
Overview
Low back pain is one of the most frequently reported musculoskeletal complaints globally. It affects individuals of all ages, especially those engaged in sedentary jobs or repetitive lifting. The condition often arises from biomechanical strain, degenerative changes, or prolonged posture issues.
- Document acuity (acute, subacute, chronic).
- Include anatomic region/level and laterality.
- Correlate symptoms with exam and imaging when used.
- Avoid unspecified codes when details exist in the note.
- Verify payer policy/LCD before procedures.
- Ensure medical necessity is explicit.
Comman symptoms
- Axial lumbar pain that may worsen with activity or prolonged sitting
- Limited flexion/extension; paraspinal tenderness
- Often mechanical; typically no red-flag systemic features
Red Flag
- Severe or progressive neurologic deficit
- Fever unexplained weight loss night sweats
- History of cancer immunosuppression or IV drug use
- Trauma with suspected fracture
- Bowel/bladder dysfunction or saddle anesthesia
At a Glance
- ICD-10 code: M54.5
- Condition: Low back pain
- Category: Low Back Pain
- Related ICD-10 codes: M54.50, M54.51, M54.59
- Common CPT links: 97161-97163, 97110, 97112, 97140, G0283, 99202-99215
- Use the most specific laterality/region code your note supports.
Overview
Low back pain is one of the most frequently reported musculoskeletal complaints globally. It affects individuals of all ages, especially those engaged in sedentary jobs or repetitive lifting. The condition often arises from biomechanical strain, degenerative changes, or prolonged posture issues.
- Document acuity (acute, subacute, chronic).
- Include anatomic region/level and laterality.
- Correlate symptoms with exam and imaging when used.
- Avoid unspecified codes when details exist in the note.
- Verify payer policy/LCD before procedures.
- Ensure medical necessity is explicit.
Causes & Risk Factors
Low back pain (M54.5) can arise from a combination of biomechanical stress, degenerative processes, systemic inflammation, or trauma. Common risk factors include aging, occupational strain, obesity, and genetic predisposition. Lifestyle factors such as poor posture, repetitive movement, or low physical conditioning also contribute to chronic musculoskeletal pain.
Diagnostic Workup
Accurate coding of Low back pain requires clear diagnostic workup. Clinicians often rely on physical examination findings such as range of motion limits, palpation tenderness, or neurovascular testing. Imaging-X-ray, MRI, or ultrasound-may confirm degenerative, inflammatory, or structural changes. Laboratory tests are typically ordered if autoimmune or metabolic causes are suspected.
Treatment & Rehabilitation
While this resource focuses on ICD-10 coding, understanding general management helps coders interpret documentation. Treatment for Low back pain may include physical therapy, posture correction, ergonomic modifications, or supervised exercise programs. Pharmacologic therapy and procedural interventions should be captured through appropriate CPT and HCPCS codes when documented. Rehabilitation aims to restore strength, range of motion, and prevent recurrence.
Prevention
Preventing recurrent musculoskeletal issues requires a holistic approach-educating patients on stretching routines, core strengthening, and activity modification. For clinicians, structured documentation templates and s can ensure accurate, defensible coding for audit readiness.
Coding Examples
- Example 1: Patient with low back pain and documented left-sided involvement - code M54.5-L.
- Example 2: Chronic pain after prior injury with imaging-confirmed degeneration - use M54.5 with chronicity modifier where applicable.
- Example 3: Bilateral presentation with limited range of motion - choose most specific laterality code variants.
Audit & Compliance
Ensure ICD-10 coding aligns with payer policies and medical necessity. Redundant use of unspecified codes is a common audit trigger. For complex cases, link diagnosis codes to procedure CPTs in the superbill and verify that documentation supports frequency and modality of care.
Clinical Example
Chief Complaint: Patient presents with low back pain over the past several weeks reporting intermittent pain and reduced function.
Subjective: The patient describes symptoms as dull aching and aggravated by movement or prolonged posture. Pain score rated 6/10 relieved partially by rest or heat.
Objective: Physical examination reveals localized tenderness reduced range of motion and no neurological deficit. Imaging reviewed indicates findings consistent with low back pain (M54.5).
Assessment: Low back pain (M54.5) - consistent with low back pain.
Plan: Continue conservative management
monitor progression and re-evaluate in 4-6 weeks. Documentation supports ICD-10 code usage as primary diagnosis.
Differential Diagnoses
When coding low back pain, consider alternative or coexisting conditions that may share similar symptoms. Accurate differentiation ensures correct ICD-10 assignment and proper claim justification.
- Herniated disc
- Facet arthropathy
- Sacroiliac joint dysfunction
- Myofascial pain syndrome
Documentation Best Practices
- Document acuity (acute subacute chronic) and laterality when available.
- Capture specific region/level (e.g. cervical vs lumbar; right vs left; primary vs secondary OA).
- Link symptoms to exam and imaging findings when relevant; avoid unsupported specificity.
- Use the most specific code supported by the note; avoid unspecified when details exist.
- Check payer policy and NCD/LCD rules; include conservative care attempts if required.
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