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New Changes to the ICD-10: Diagnosing Lower Back Pain

Andrea Ryan
October 19, 2021

There has been a recent development in the lives of providers and front office staff at therapy offices around the country, and to say it has been a pain in the back is to put it mildly. Beginning Oct. 1, one of the most common CMS codes used by physical therapy practices has been removed. This is not a rare occurrence, every year CMS releases a list of changes that are to be made to the Medicare program along with any other changes to the rules and regulations governing healthcare. 

What is CMS and how does it relate to ICD-10 codes

The CMS, or the Center for Medicare and Medicaid Services, is a governmental agency that regulates the assignment of ICD-10 codes to specific diagnoses in medicine and therapy practice. Not quite sure how the ICD-10 manual and CPT codes relate to your physical therapy practice, check out this post.

Each year they release a report that tends to adjust or change different parts of the ICD-10 manual in an effort to make the numerical codes assigned during the treatment process more universal. As a medical professional, you probably understand that these alterations can often have the opposite effect. Though CMS guidance on treatment coding technically only applies to reimbursement from Medicare and Medicaid, the system has also been adopted by private insurers. 

M54.5 is no more

This year, one of the major adjustments that relates to physical therapy practices is the removal of the code M54.5, which is generally used to document lower back pain.  Lower back pain is the most common cause of disability in all age groups and accounts for one-fourth to one-third of all causes of disabilities. Lower back pain can be caused by injury, overuse or simply wear and tear on the structures related to normal spine function.

As these conditions are so prevalent among individuals seeking physical therapy treatment, it comes as no surprise that the lower back pain designation is used quite often. The CSM series codes were designed primarily for insurance companies by physicians with little knowledge about the field of physical therapy. Many insurers require documentation using this number in order to authorize payment for services rendered in the physical therapy setting. Failure to use these codes according to contracted guidelines may result in denial of payment from insurance carriers who rely on these numbers when determining the eligibility of services for their insured. 

The reason that the M54.5 codes were discontinued, according to CSM, is that the diagnosis of lower back pain is too broad and doesn’t truly define how or why a patient is experiencing the issue.  Lower back pain is a very common problem encountered in daily clinical practice, and therefore was an extremely common code seen by insurance providers. As common as lower back pain is, the causes for it are extremely varied, however. In an effort to make the ICD-10 system more descriptive, CMS eliminated M54.5 entirely and is now only accepting much more specific diagnoses for treatment of lower back pain.

The new lower back pain codes prescribed by the CMS may change the way physical therapists diagnose and treat patients.

The new lower back pain codes

To supplement this low back coding deletion, CMS suggests that providers use other, more specific codes—some which you may recognize, and some of which are totally new. Here are some of the available codes that may replace M54.5 and should be used after October 1:

S39.012: Low back strain

M51.2-:  Lumbago due to intervertebral disc displacement

M54.4-: Lumbago with sciatica

M54.50: Low back pain, unspecified

M54.51: Vertebrogenic low back pain

M54.59: Other low back pain

S37.401A: Unspecified trauma to intervertebral disc, initial encounter

S37.401D: Unspecified trauma to intervertebral disc, subsequent encounter

S37.401S: Unspecified trauma to intervertebral disc, sequela

The CMS recommends that as a therapist in a treatment setting, you should be as specific as possible in order to avoid an Excludes1 edit upon submission.

Other notable changes

Deletion of M54.5 from the ICD-10 is likely the biggest change that will affect physical therapy practices, but there are other notable shifts in coding for other diagnoses that you may want to be aware of. Both R05 – Cough and R63.3 – Feeding difficulties were also slated for removal. Again, the reason given for removal of these codes is that each is too broad and doesn’t adequately describe a true diagnosis. 

What does this mean for your therapy practice

Generally, the result of these changes is that as a provider you will need to determine a much more specific diagnosis and treatment plan for a new or returning patient before applying and ICD-10 code to their file. Pre-authorizations may be more detailed in light of the change to the ICD-10.  This will likely result in longer authorizations.

Probably even more notable is the effect changes that CMS makes on the billing and reimbursement procedure for therapy practice front office staff. The reimbursement process from both Medicare, Medicaid and private insurers may be slightly more difficult as your billing department adjusts to the deletion of such an important code.

 Lower back pain remains a common complaint for patients seeking treatment from physical therapists across the nation. This change has generated considerable concern among therapists that this move will eliminate payment for many treatments involving lower back pain diagnosis/treatment, including lumbar spine stabilization exercises. Keeping informed about the adjustment to how treatment for lower back pain should be coded though, should prevent any confusion. 

Also, keep in mind that there are services like the all inclusive revenue cycle management offered by PatientStudio that provide completely up to date coding guidance. They can guarantee that changes like the one we have discussed don’t result in changes to your bottom line.


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