Low Back Pain ICD-10-CM codes

M54.5 stopped being a valid code on October 1, 2021. Low back pain now requires a 5th character: M54.50 for low back pain unspecified (lumbago NOS), M54.51 for vertebrogenic low back pain, and M54.59 for other low back pain. M54.51 is meant for pain the provider attributes to vertebral endplate changes and should only be assigned when the documentation states vertebrogenic or clearly links the pain to endplate pathology. M54.59 captures documented low back pain that is neither unspecified nor vertebrogenic, such as pain described as mechanical or muscular.

M54.5- has Excludes1 notes that matter in practice. Low back pain with sciatica is coded to M54.4- (M54.41 right, M54.42 left, M54.40 unspecified side), not to M54.5- plus M54.3-. Low back pain due to a documented disc displacement is coded to M51.2- and low back pain from a low back strain is S39.012-; in both cases M54.5- is not added. Pain in the thoracic spine is M54.6, and back pain with no region stated is M54.9.

When the provider documents chronic low back pain, add G89.29 (other chronic pain) to the M54.5- code; G89.4 (chronic pain syndrome) is assigned only when that exact diagnosis is documented. Sequencing follows the chapter 6 pain guideline: the G89 code goes first when pain management is the reason for the encounter and the site code follows; when the encounter is for evaluation of the back problem itself, the M54.5- code is first. A symptom code is not reported once a definitive cause such as spinal stenosis or spondylolisthesis is established.