Revenue Cycle Insider

Question: A patient presented with lower back pain on the left side. The radiologist captured three X-ray views of the entire thoracic and lumbar spine. The results were unremarkable. I’m new to radiology coding, and I’m unsure if I should report an “other” or “unspecified” diagnosis code. Can you help?

Revenue Cycle Insider Subscriber

Answer: You’ll assign an unspecified diagnosis code, such as M54.50 (Low back pain, unspecified), for this situation. The patient presented to the clinic with a complaint of low back pain that happened to be occurring on the left side of the body.

Since the “left side” is describing which side is affected by the lower back pain, “it would be inappropriate to classify left-sided low back pain to code M54.59, Other low back pain,” according to the AHA^® ICD-10-CM/PCS Coding Clinic, Volume 13, Issue 1.

Mike Shaughnessy, BA, CPC, Production Editor, AAPC