Radiology Coding Alert

Reader Questions:

Leave Low Back Pain Off Your Claim When Reporting M43.16

Published on Tue Feb 22, 2022

Question: Our radiologist captured two X-ray views of a 75-year-old patient’s L1-L5 vertebrae. The patient was referred to our radiology practice by their physician after presenting with chronic low back pain. The patient’s history indicated their condition has set in over time and they didn’t experience any trauma recently. The radiologist interpreted the views and reported the results with a diagnosis of chronic low back pain due to lumbar spondylolisthesis.

Do I report the chronic low back pain or the lumbar spondylolisthesis as the diagnosis?

Alaska Subscriber

Answer: You need to report only M43.16 (Spondylolisthesis, lumbar region) for this diagnosis. Low back pain is a symptom of spondylolisthesis, so including a low back pain code, such as M54.50 (Low back pain, unspecified), in your claim is unnecessary. Lumbar spondylolisthesis occurs during the aging process and with wear and tear on the spinal joints. The condition is also caused by stress fractures, infection, or other conditions, such as arthritis.

Excludes1 note: Subcategory M43.1- (Spondylolisthesis) features an Excludes1 note that references the following acute traumatic or congenital condition codes:

S33.1- (Subluxation and dislocation of lumbar vertebra)
Q76.2- (Congenital spondylolisthesis)

The Excludes1 note listing S33.1- tells you not to use M43.1- if the condition is described as “acute traumatic of lumbosacral region.” This synonym can be considered an unwritten descriptor for S33.1- since it’s not listed in your ICD-10-CM code set with that subcategory.

To better understand the Excludes1 note, remember that spondylolisthesis, coded to M43.1-, happens over time as opposed to being an acute condition that’s caused by trauma (coded to S33.1-) or is congenital (coded to Q76.2-). “The Excludes1 note is to confirm the diagnosis, and cannot be a condition of time and trauma/congenital. It has to be one or the other,” says Kristen R. Taylor, CPC, CHC, CHIAP, associate partner of Pinnacle Enterprise Risk Consulting Services in Columbia, South Carolina.