ICD-10 M54.5 Phased Out as of October 1, 2021

  • September 30, 2021
  • news

According to the Centers for Medicare & Medicaid Services (CMS), there will be an update to the ICD-10 manual, likely affecting many therapists.

Every October, there are changes made to the ICD-10 manual, which include replacement, removal, and addition of codes. The change this October 1st, will affect a common code used by many rehab professionals – low back pain (M54.5). This means that if are using M54.5 on your documentation and billing on or after October 1, you risk getting denied from reimbursement. To maintain compliance with the updated codes, any existing or new patients will need to have an updated version of this code, such as the above examples. These changes to the ICD-10 manual will affect all payers, including Medicare, Medicaid, and private/commercial insurances.

Beginning Oct. 1: Stop Using This ICD-10 Code for LBP. This code will be replaced with more specific codes to use, such as:
M54.50 (Low back pain, unspecified)
M54.51 (Vertebrogenic low back pain)
M54.59 (Other low back pain)

Please be aware that for some payers, it may take time to update their databases and you may find a denial, even though you billed one of the new codes properly. This may lead to requiring a re-submission or an appeal process, so be ready! Please review your documentation, and make sure to revise the code as needed per medical necessity. You may risk getting a denial or rejection from insurance payers if billing this code after October 1st, 2021

There are other changes made to ICD-10 codes, for a full list, please visit: https://www.cms.gov/medicare/icd-10/2022-icd-10-cm

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