ICD Code M54.41

ICD code M54.41 is a medical classification used to denote the condition of lumbago with sciatica on the right side. This code is part of the International Classification of Diseases, 10th Revision (ICD-10), and it specifically identifies a situation where a patient is experiencing lower back pain (lumbago) that is accompanied by sciatica, which is pain that radiates along the path of the sciatic nerve, affecting the right side of the body. This condition can result in symptoms such as sharp pain, tingling, or numbness that extends from the lower back down through the buttock and leg. Proper documentation of this code is crucial for accurate billing and treatment planning in healthcare settings.

1. Presence of Lower Back Pain: The patient must exhibit significant pain localized in the lower back region. This pain is often described as a dull, aching sensation but can also present as sharp or stabbing.

2. Radiating Pain to the Right Leg: The pain should extend from the lower back down the right leg, following the path of the sciatic nerve. This radiating pain is a hallmark symptom and is often described as shooting or burning.

3. Numbness or Tingling Sensation: The patient may experience numbness or a tingling sensation in the right leg, which can extend to the foot. This sensory disturbance is indicative of nerve involvement.

4. Muscle Weakness in the Right Leg: There may be noticeable weakness in the muscles of the right leg, affecting the patient's ability to perform normal activities such as walking or standing.

5. Positive Straight Leg Raise Test: During a physical examination, a positive result on the straight leg raise test, where lifting the right leg while lying flat causes pain, can support the diagnosis.

6. Exclusion of Other Causes: Other potential causes of the symptoms, such as fractures, tumors, or infections, should be ruled out through appropriate diagnostic imaging or tests.

7. Chronicity of Symptoms: The symptoms should be persistent or recurrent over a period of time, typically lasting more than a few weeks, to differentiate from acute injuries or transient conditions.

8. Impact on Daily Activities: The condition should significantly impact the patient's daily activities and quality of life, necessitating medical intervention or management.

By meeting these criteria, healthcare providers can accurately determine when to use the specific ICD code for this condition.

For the ICD code M54.41 (Lumbago with sciatica, right side), the relevant CPT codes that may be applicable for treatment include:

1. 99201-99205 - Office or other outpatient visit for the evaluation and management of a new patient.

2. 99211-99215 - Office or other outpatient visit for the evaluation and management of an established patient.

3. 20552 - Injection(s); single or multiple trigger point(s), 1 or 2 muscle(s).

4. 20553 - Injection(s); single or multiple trigger point(s), 3 or more muscles.

5. 20610 - Arthrocentesis, aspiration, and/or injection into a major joint or bursa (e.g., hip, knee, shoulder joint, bursa).

6. 97110 - Therapeutic exercises to develop strength and endurance, range of motion, and flexibility.

7. 97140 - Manual therapy techniques (e.g., mobilization/manipulation, manual lymphatic drainage, manual traction), one or more regions, each 15 minutes.

8. 97032 - Application of a modality to one or more areas; electrical stimulation (manual), each 15 minutes.

9. 97035 - Application of a modality to one or more areas; ultrasound, each 15 minutes.

10. G0283 - Electrical stimulation (unattended), to one or more areas for indications other than wound care, as part of a therapy plan of care.

These CPT codes are examples of procedures and services that may be used in the treatment of lumbago with sciatica on the right side. It's important to verify the specific services provided and consult the latest CPT code set for accurate coding and billing.

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