Diseases of the musculoskeletal system and connective tissue
ICD-10 Code: M54.5
Low Back Pain
M54.5 is used to code low back pain (lumbago) when no specific underlying cause has been identified. This is one of the most common musculoskeletal diagnoses in primary care.
Clinical Information
Low back pain is pain and discomfort localized below the costal margin and above the inferior gluteal folds, with or without leg pain. It is one of the most common reasons for medical visits.
**Key Characteristics:**
- Can be acute (<4 weeks), subacute (4-12 weeks), or chronic (>12 weeks)
- Often mechanical in nature (muscle strain, ligament sprain)
- May be associated with poor posture, lifting, or repetitive motions
- Most cases are self-limiting and resolve within 4-6 weeks
Coding Guidelines
- 1Use M54.5 for nonspecific low back pain without radiculopathy
- 2If sciatica is present, use M54.3- or M54.4- instead
- 3Specify acute, subacute, or chronic in documentation (though not required for M54.5)
- 4Do not use if specific cause identified (e.g., herniated disc, spinal stenosis)
- 5Code separately any associated conditions (obesity, muscle spasm)
Common Uses
- Acute low back strain from lifting or injury
- Chronic mechanical low back pain
- Lumbago without radiculopathy or sciatica
- Low back pain for physical therapy referral
- Work-related back pain without specific injury
Related ICD-10 Codes
M54.16Radiculopathy, lumbar region
M54.30Sciatica, unspecified side
M51.26Other intervertebral disc displacement, lumbar region
M48.06Spinal stenosis, lumbar region
S39.012AStrain of muscle, fascia and tendon of lower back, initial encounter
Documentation Requirements
- Specify location of pain (lumbar region, L1-L5 levels if known)
- Document duration (acute vs. chronic)
- Note absence or presence of radicular symptoms
- Include aggravating/alleviating factors
- Document functional limitations
- Record results of physical exam (range of motion, straight leg raise, neurological exam)
Real-World Coding Examples
45-year-old presents with acute onset low back pain after lifting. No radiation to legs. → M54.5
Patient with chronic low back pain x 6 months, no sciatica. Pain localized to lumbar region. → M54.5
Office worker with mechanical low back pain, worse with prolonged sitting. No radiculopathy. → M54.5
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