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ICD-10 Coding for Lumbar Stenosis(M48.061, M48.062)

Complete ICD-10-CM coding and documentation guide for Lumbar Stenosis. Includes clinical validation requirements, documentation requirements, and coding pitfalls.

Also known as:

Spinal StenosisLumbar Spinal Stenosis

Related ICD-10 Code Ranges

Complete code families applicable to Lumbar Stenosis

M48.06-M48.069Primary Range

Spinal stenosis, lumbar region

This range includes specific codes for lumbar stenosis with and without neurogenic claudication.

Code Comparison: When to Use Each Code

Compare key differences between these codes to ensure accurate selection

CodeDescriptionWhen to UseKey Documentation
M48.061Spinal stenosis, lumbar region without neurogenic claudicationUse when lumbar stenosis is present without symptoms of neurogenic claudication.
  • MRI showing lumbar stenosis without nerve compression
  • Absence of leg pain worsened by walking
M48.062Spinal stenosis, lumbar region with neurogenic claudicationUse when lumbar stenosis is present with symptoms of neurogenic claudication.
  • MRI showing lumbar stenosis with nerve root compression
  • Symptoms of leg pain relieved by sitting

Clinical Decision Support

Always review the patient's clinical documentation thoroughly. When in doubt, choose the more specific code and ensure documentation supports it.

Key Information: ICD-10 code for lumbar stenosis with neurogenic claudication

Essential facts and insights about Lumbar Stenosis

The ICD-10 code for lumbar stenosis with neurogenic claudication is M48.062, requiring documentation of symptoms like leg pain relieved by sitting.

Primary ICD-10-CM Codes for lumbar stenosis

Spinal stenosis, lumbar region without neurogenic claudication
Billable Code

Decision Criteria

clinical Criteria

  • MRI shows stenosis without nerve compression

documentation Criteria

  • No mention of neurogenic claudication symptoms

Applicable To

  • Lumbar stenosis without neurogenic claudication

Excludes

Clinical Validation Requirements

  • MRI showing lumbar stenosis without nerve compression
  • Absence of leg pain worsened by walking

Code-Specific Risks

  • Incorrectly coding when neurogenic symptoms are present

Coding Notes

  • Ensure documentation clearly states the absence of neurogenic claudication.

Ancillary Codes

Additional codes that should be used in conjunction with the main diagnosis codes when applicable.

Low back pain

M54.5
Use if low back pain is the primary complaint without radiculopathy.

Neurogenic claudication

G99.2
Use if neurogenic claudication is secondary to another condition.

Differential Codes

Alternative codes to consider when ruling out similar conditions to the primary diagnosis.

Spinal stenosis, lumbar region with neurogenic claudication

M48.062
Presence of neurogenic claudication symptoms such as leg pain relieved by sitting.

Spinal stenosis, lumbar region without neurogenic claudication

M48.061
Absence of neurogenic claudication symptoms.

Documentation & Coding Risks

Avoid these common documentation and coding issues when documenting Lumbar Stenosis to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code M48.061.

Impact

Clinical: Inaccurate diagnosis and treatment planning., Regulatory: Non-compliance with coding guidelines., Financial: Potential claim denials or reduced reimbursement.

Mitigation Strategy

Use specific symptom descriptions, Include imaging findings

Impact

Reimbursement: Non-specific codes may lead to claim denials., Compliance: Non-compliance with specificity requirements., Data Quality: Decreased accuracy in clinical data.

Mitigation Strategy

Use M48.061 or M48.062 based on the presence of neurogenic claudication.

Impact

Risk of using non-specific codes leading to audit flags.

Mitigation Strategy

Ensure documentation supports the specific code used.

Documentation errors, coding pitfalls, and audit risks are interconnected aspects of medical coding and billing. Addressing all three areas helps ensure accurate coding, optimal reimbursement, and regulatory compliance.

Frequently Asked Questions

Common questions about ICD-10 coding for Lumbar Stenosis, with expert answers to help guide accurate code selection and documentation.

Documentation Templates for Lumbar Stenosis

Use these documentation templates to ensure complete and accurate documentation for Lumbar Stenosis. These templates include all required elements for proper coding and billing.

Neurology Progress Note for Lumbar Stenosis

Specialty: Neurology

Required Elements

  • Patient history
  • Physical exam findings
  • Imaging results
  • Assessment and plan

Example Documentation

**Subjective**: "75yo F c/o inability to walk >5 minutes without bilateral leg cramps. Relief within 3 minutes of sitting. Denies bowel/bladder changes." **Objective**: MRI: "Severe central canal stenosis L3-L4 (7mm AP diameter)" EMG: "L4 radiculopathy" **Assessment**: "Lumbar spinal stenosis with neurogenic claudication (M48.062)" **Plan**: "Refer to PT for flexion-based exercises; consider interlaminar epidural (CPT 62323)"

Examples: Poor vs. Good Documentation

Poor Documentation Example
"Low back pain with leg numbness."
Good Documentation Example
"Severe lumbar stenosis at L4-L5 on MRI with neurogenic claudication: leg pain after 200 feet of walking, resolves within 2 minutes of sitting. Failed 8 weeks of PT."
Explanation
The good example includes specific symptoms and imaging findings, meeting documentation requirements.

Need help with ICD-10 coding for Lumbar Stenosis? Ask your questions below.

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