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Are the new DX Code changes causing you GRIEF?

Updated: Nov 3, 2021

As of October 1, 2021 there have been some changes in diagnosis codes that are affecting claims with some of our Pain Management Practices, Here's a quick breakdown of what's changed.

October is the beginning of fall, cooler weather, and of course Halloween frights.

CMS has added some neat little surprises to cause some hair raising chills as well.

Don't get too alarmed, everything is changing at a rapid pace as we start to transition back to billing after the pandemic. There will be some drastic good changes, and we all know too well, some let's just say some really painful ones that have cut into both practices' revenue as well as affecting patient care. In the interest of being brief, I will just talk about the recent retiring of a few diagnosis codes.


the following originally posted on WebPT ~ Author- Melissa Hughes


M54.5 is No More: The Scoop on ICD-10’s Low Back Pain Code Change ICD-10 code M54.5 is soon to be a relic of the past.

This year, alongside the 2022 proposed rule and the quarterly NCCI edit changes, CMS announced some updates to the ICD-10 manual—and you’re gonna want to know about them. Here’s what’s happening.

ICD-10 code M54.5 is getting the kibosh.

Every year, CMS publishes updates to the ICD-10 manual, deleting unnecessary codes, adding new ones, and revising language as-needed. This August, CMS published its latest round of ICD-10 changes—including the deletion of ICD-10 code M54.5, low back pain, effective October 1, 2021.

That means providers cannot use M54.5 to specify a diagnosis on or after October 1—and existing patients with the M54.5 diagnosis will need to be updated to a valid ICD-10 code. This is one of the most commonly billed codes in the pain management industry, and our compliance experts predict that this change will heavily affect the coding habits of many (if not most) pain management practitioners.

Providers will need to get specific, using more detailed (and sometimes new) ICD-10 codes to describe low back pain.

So, here’s the real question: How the heck can CMS justify deleting such a commonly used code? Well, CMS has explained that it’s deleting M54.5 because it lacks specificity (and we all know how important coding specificity is to ICD-10). To supplement this low back coding deletion, CMS suggested that providers use other, more specific codes—some which you may recognize, and some of which are totally new. Here are some potential code replacements that you can use beginning October 1:

  • S39.012, Low back strain

  • M51.2-, Lumbago due to intervertebral disc displacement

  • M54.4-, Lumbago with sciatica

  • M54.50, Low back pain, unspecified

  • M54.51: Vertebrogenic low back pain

  • M54.59: Other low back pain

Please note that using S39.012, M51.2-, or M54.4- in addition to M54.5- will likely result in an Excludes1 edit.

Prepare for payer pushback.

When CMS edits the ICD-10 manual, those changes apply to all payers—Medicare, state, and commercial alike. That said, some commercial payers don’t have the best track record when it comes to applying these changes in a timely manner. So it’s possible that come October 1, you may bill a new code (e.g., M54.51) and receive a denial until the payer updates its policies. Alternatively, even if you successfully bill M54.5, you may face retractions from the payer somewhere down the line. Best practice is to stick to the latest version of the ICD-10 manual and prepare to appeal, appeal, appeal.

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