M54.50 — Low back pain, unspecified
ICD-10-CM
Prior Authorization
No Prior Auth Required
No active coverage policies found for this code (low confidence)
Documentation Required
- The medical record must include the legible signature of the physician or non-physician practitioner responsible for and providing care to the patient.
- Documentation of medical necessity for testing must be maintained in the patient's medical record and must conform to the documentation requirements in LCD L36393.
- Every page of the medical record must be legible and include appropriate patient identification information (e.g., complete name, dates of service).
- The submitted medical record must support the use of the selected ICD-10-CM code(s) and the submitted CPT/HCPCS code must accurately describe the service performed.
Key Coverage Criteria
- Controlled substance monitoring and drugs-of-abuse testing are covered when individually ordered by the treating clinician and meet the reasonable and necessary requirements specified in LCD L36393.
- Duplex scanning is covered only when it meets the reasonable and necessary requirements specified in Local Coverage Determination L33674.
- NC-stat testing (CPT 95905) is allowed when the beneficiary has a high pre-test or prior probability of Carpal Tunnel Syndrome (CTS), limited to one service per arm.
- Use CPT 95870 for sampling muscles other than the paraspinals associated with the extremities that have been tested.
- Coverage for amniotic and placental-derived product injections/applications for musculoskeletal, non-wound indications is determined by Local Coverage Determination L39139; consult LCD L39139 for specific clinical indications and thresholds.
- MS testing is covered when performed in accordance with the applicable Local Coverage Determination (LCD) coverage guidelines for monoclonal gammopathy.
20 Active Policies
A59434 — Billing and Coding: Amniotic and Placental-Derived Product Injections and/or Applications for Musculoskeletal Indications, Non-Wound
J05
A59553 — Billing and Coding: Trigger Point Injections
J05
L39713 — Trigger Point Injections
J05
L39624 — Amniotic and Placental Derived Product Injections and/or Applications for Musculoskeletal Indications, Non-Wound
J05
Related Codes
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