ICD Code M48.061

ICD code M48.061 is a medical classification used to denote spinal stenosis in the lumbar region without the presence of neurogenic claudication. This condition involves a narrowing of the spinal canal in the lower back, which can lead to compression of the spinal nerves, but in this case, it does not result in the specific symptom of neurogenic claudication, which typically includes pain and discomfort in the legs when walking or standing.

1. Chronic Lower Back Pain: Persistent pain in the lumbar region that does not resolve with standard treatment and is not associated with neurogenic claudication.

2. Radiological Evidence: Imaging studies such as MRI or CT scans showing narrowing of the spinal canal in the lumbar region without any signs of nerve root compression or neurogenic claudication.

3. Limited Range of Motion: Reduced flexibility and movement in the lower back, which may be observed during a physical examination.

4. Absence of Neurogenic Claudication: No symptoms of neurogenic claudication, such as pain, tingling, or weakness in the legs that worsen with walking or standing and improve with sitting or bending forward.

5. Normal Neurological Examination: Neurological tests do not reveal any deficits such as muscle weakness, sensory loss, or reflex changes that would indicate nerve involvement.

6. Exclusion of Other Conditions: Rule out other potential causes of lumbar pain, such as herniated discs, fractures, or infections, through appropriate diagnostic testing.

7. Patient History: A detailed patient history that supports the presence of spinal stenosis in the lumbar region without any neurogenic symptoms, including the duration and nature of the pain.

8. Response to Conservative Treatment: Documented response to conservative management strategies such as physical therapy, anti-inflammatory medications, or lifestyle modifications, without improvement in symptoms indicative of neurogenic claudication.

For the ICD code M48.061, which pertains to spinal stenosis in the lumbar region without neurogenic claudication, the relevant CPT codes that may be applicable for treatment include:

1. 63030 - Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc; 1 interspace, lumbar.

2. 63047 - Laminectomy, facetectomy and foraminotomy (unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root(s)), single vertebral segment; lumbar.

3. 22612 - Arthrodesis, posterior or posterolateral technique, single level; lumbar (with lateral transverse technique, when performed).

4. 22842 - Posterior segmental instrumentation (e.g., pedicle fixation, dual rods with multiple hooks and sublaminar wires); 3 to 6 vertebral segments.

5. 22853 - Insertion of interbody biomechanical device(s) (e.g., synthetic cage(s), mesh(es), methylmethacrylate) with integral anterior instrumentation for device anchoring (e.g., screws, flanges), when performed, to intervertebral disc space in conjunction with interbody arthrodesis, each interspace (list separately in addition to code for primary procedure).

These CPT codes are commonly associated with surgical procedures that may be performed to address the condition described by ICD code M48.061. It is important for healthcare providers to verify the specific procedures required for each patient and ensure accurate coding for billing and reimbursement purposes.

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