ICD Code M54.18

ICD code M5418 is used to identify and classify a medical condition known as radiculopathy in the sacral and sacrococcygeal region. Radiculopathy refers to a condition where one or more nerves are affected and do not work properly, which can result in pain, weakness, numbness, or difficulty controlling specific muscles. The sacral and sacrococcygeal region pertains to the lower part of the spine, near the pelvis and tailbone. This code is crucial for healthcare providers as it helps in accurately documenting the diagnosis, facilitating appropriate treatment plans, and ensuring proper billing and reimbursement processes within the healthcare revenue cycle.

When to use the ICD code for radiculopathy in the sacral and sacrococcygeal region, consider the following diagnostic criteria and symptoms:

1. Patient History
- Presence of lower back pain or discomfort.
- History of trauma or injury to the lower back or pelvis.

2. Neurological Symptoms
- Numbness or tingling sensations in the lower extremities.
- Weakness in the legs or feet.
- Difficulty in walking or maintaining balance.

3. Pain Characteristics
- Radiating pain from the lower back into the buttocks, thighs, or legs.
- Pain that worsens with certain movements or positions, such as sitting or standing.

4. Physical Examination Findings
- Positive straight leg raise test or other provocative tests indicating nerve root involvement.
- Reduced reflexes in the lower extremities.

5. Imaging Studies
- MRI or CT scan findings showing disc herniation, spinal stenosis, or other structural abnormalities affecting the sacral or sacrococcygeal region.

6. Electromyography (EMG) Results
- Evidence of nerve root compression or dysfunction in the sacral region.

7. Exclusion of Other Conditions
- Ruling out other potential causes of lower back pain and neurological symptoms, such as fractures, tumors, or infections.

8. Duration of Symptoms
- Symptoms persisting for a specific duration, typically more than a few weeks, indicating chronicity.

By adhering to these criteria, healthcare providers can accurately determine the necessity of using the appropriate ICD code for radiculopathy in the sacral and sacrococcygeal region.

For the ICD code M54.18, which pertains to radiculopathy in the sacral and sacrococcygeal region, the relevant CPT codes that may be applicable for treatment include:

1. CPT 20552 - Injection(s); single or multiple trigger point(s), 1 or 2 muscle(s).

2. CPT 20553 - Injection(s); single or multiple trigger point(s), 3 or more muscles.

3. CPT 20610 - Arthrocentesis, aspiration and/or injection into a major joint or bursa (e.g., sacroiliac joint).

4. CPT 62322 - Injection(s), of diagnostic or therapeutic substance(s) (e.g., anesthetic, antispasmodic, opioid, steroid), not including neurolytic substances, including needle or catheter placement, interlaminar epidural or subarachnoid, lumbar or sacral (caudal); without imaging guidance.

5. CPT 62323 - Injection(s), of diagnostic or therapeutic substance(s) (e.g., anesthetic, antispasmodic, opioid, steroid), not including neurolytic substances, including needle or catheter placement, interlaminar epidural or subarachnoid, lumbar or sacral (caudal); with imaging guidance (e.g., fluoroscopy or CT).

6. CPT 64483 - Injection(s), anesthetic agent and/or steroid, transforaminal epidural; lumbar or sacral, single level.

7. CPT 64484 - Injection(s), anesthetic agent and/or steroid, transforaminal epidural; lumbar or sacral, each additional level (List separately in addition to code for primary procedure).

8. CPT 64635 - Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); lumbar or sacral, single facet joint.

9. CPT 64636 - Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); lumbar or sacral, each additional facet joint (List separately in addition to code for primary procedure).

These CPT codes are examples of procedures that might be used to treat conditions associated with the ICD code M54.18. It's important for healthcare providers to select the most appropriate CPT code based on the specific treatment plan and services provided to the patient.

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