ICD Code M54.9

ICD code M549 is used to classify a condition known as "Dorsalgia, unspecified." This code is part of the International Classification of Diseases (ICD) system, which is used by healthcare providers to document and categorize diagnoses. "Dorsalgia" refers to pain located in the back, but the term "unspecified" indicates that the exact nature or cause of the back pain has not been clearly identified or detailed in the medical record. This code is typically used when a patient presents with back pain, but further diagnostic information is not available or has not been provided.

When to use the ICD code for dorsalgia, unspecified:

1. Patient Presentation: The patient reports back pain without a specified cause or diagnosis.

2. Duration of Symptoms: The back pain has been persistent for a duration that does not warrant a more specific diagnosis (e.g., acute vs. chronic).

3. Diagnostic Imaging: Imaging studies (e.g., X-rays, MRIs) do not reveal any identifiable structural abnormalities or specific conditions.

4. Physical Examination Findings: The physical examination shows tenderness or discomfort in the back region but lacks neurological deficits or signs of serious underlying conditions.

5. Exclusion of Other Conditions: Other potential causes of back pain (e.g., fractures, infections, tumors) have been ruled out through clinical evaluation and diagnostic testing.

6. Symptom Description: The patient describes the pain as general or diffuse, without specific localization or characteristics that would suggest a more defined diagnosis.

7. Response to Treatment: The patient has not responded to initial conservative treatments (e.g., rest, physical therapy) but does not exhibit symptoms that would necessitate a more specific diagnosis.

8. Follow-Up Visits: During follow-up visits, the patient continues to report back pain without any new findings that would lead to a more specific diagnosis.

9. Documentation: The healthcare provider documents the patient's symptoms and the rationale for using an unspecified code, ensuring clarity in the medical record.

For the ICD code M54.9 (Dorsalgia, unspecified), the relevant CPT codes that may be applicable for treatment can include, but are not limited to, the following:

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

2. 99211-99215 - Established patient office or other outpatient visit for the evaluation and management of a patient.

3. 97110 - Therapeutic exercises to develop strength and endurance, range of motion, and flexibility.

4. 97140 - Manual therapy techniques (e.g., mobilization/manipulation, manual lymphatic drainage, manual traction).

5. 97010 - Application of a modality to one or more areas; hot or cold packs.

6. 97035 - Application of a modality to one or more areas; ultrasound, each 15 minutes.

7. 20552 - Injection(s); single or multiple trigger point(s), 1 or 2 muscle(s).

8. 20610 - Arthrocentesis, aspiration, and/or injection into a major joint or bursa (e.g., shoulder, hip, knee joint, subacromial bursa).

These CPT codes are examples of procedures and services that might be used in the treatment of conditions associated with dorsalgia. It is important for healthcare providers to select the most appropriate CPT code based on the specific services rendered and the clinical scenario. Always ensure that the chosen CPT codes align with the documentation and medical necessity for the services provided.

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