Chiropractic Coding & Compliance Alert

Question: A patient comes in with low back pain and the provider diagnoses a subluxation at the lumbar level. The patient also has postural lumbosacral lordosis. This patient has been treated for a sacroiliac sprain earlier and now has come with recurrence of pain in the region. How shall we proceed with coding this scenario under ICD-10?

Wyoming Subscriber

Answer: The primary diagnosis for this patient should be M99.03 (Segmental and somatic dysfunction of lumbar region). You can add the secondary diagnoses:

• M40.47, Postural lordosis, lumbosacral region
  
• S33.6XXD, Sprain of sacroiliac joint, subsequent encounter.
  

Since the patient has already been to your provider for the problem related to sacroiliac sprain, this does not amount to an initial visit and would rather be counted as a subsequent encounter.

 

 

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