M54.16 – Radiculopathy, lumbar region

M54.16 Diagnosis Code: Radiculopathy, lumbar region

• Radiculopathy refers to a condition characterized by the compression or irritation of one or more nerve roots in the spinal region, leading to sensory, motor, or reflex disturbances.
• M54.16 specifically identifies radiculopathy in the lumbar (lower back) region.
• The code includes radiculopathy resulting from intervertebral disc disorders, degenerative changes in the spine, and other related conditions.
• The lumbar region encompasses the five lower vertebrae (L1-L5) and the spinal nerves.
• Radiculopathy in the lumbar region often presents with symptoms such as lower back pain, radiating leg pain (sciatica), numbness, tingling, and muscle weakness.
• Herniated discs, spinal stenosis, spondylolisthesis, and other structural abnormalities in the lumbar spine can cause it.
• Diagnosis of M54.16 requires clinical evaluation, medical history review, and imaging studies to identify the underlying cause and location of nerve root compression or irritation.

Is M54.16 Billable: Yes

Yes, M54.16 – Radiculopathy, lumbar region is a billable code in the International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) system. It can be used for healthcare billing, insurance reimbursement, and statistical purposes. 

When documenting the diagnosis of radiculopathy in the lumbar region, the appropriate ICD-10-CM code (M54.16) should be assigned to represent the condition and facilitate proper billing procedures accurately.

Clinical Information

Radiculopathy in the lumbar region may manifest with the following clinical information:

• Lower back pain radiating to the buttocks, hips, or legs.
• Sensory disturbances include numbness, tingling, or a "pins and needles" sensation.
• Muscle weakness or loss of reflexes in the lower extremities.
• Aggravation of symptoms with certain movements, such as bending, twisting, or prolonged sitting.
• Potential involvement of multiple nerve roots in the lumbar spine.
• Varying degrees of pain intensity range from mild discomfort to severe, debilitating pain.
• Symptoms such as coughing or sneezing may worsen with activities that increase pressure on the affected nerve roots.
• Diagnostic tests, including imaging studies (e.g., MRI, CT scan), electromyography (EMG), and nerve conduction studies, can aid in confirming the diagnosis and identifying the underlying cause.

Synonyms Include:

• Radiculopathy, lumbar
• Lumbar nerve root compression
• Lumbosacral radiculopathy
• Lumbar radiculitis
• Sciatica, lumbar region
• Lumbosacral nerve root disorder

Other ICD-10 Codes Commonly Used for Lumbar Region

• M54.30 – Sciatica, unspecified side
• M54.31 – Sciatica, right side
• M54.32 – Sciatica, left side
• M51.36 – Other intervertebral disc degeneration, lumbar region
• M48.06 – Spinal stenosis, lumbar region
• M43.16 – Spondylolisthesis, lumbar region
• M47.816 – Other spondylosis with radiculopathy, lumbar region
• M54.5 – Low back pain
• M54.17 – Radiculopathy, sacral region
• M54.4 – Lumbago with sciatica