M54.5 is No More: The Scoop on ICD-10's Low Back Pain Code Change

The orangest season of the year is almost upon us—but autumn heralds far more than just colorful leaves, cooler weather, and pumpkin spice everything. It also signals the beginning of compliance season: the time of year when CMS publishes a large number of changes to the Medicare program and other healthcare rules and regulations. 

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 rehab therapy industry, and our compliance experts predict that this change will heavily affect the coding habits of many (if not most) rehab therapists. 

That’s not the only ICD-10 code on the outs. 

The deletion of M54.5 is not the only one that may cause waves for rehab therapists (even though it will cause the biggest disturbance). The WebPT team also identified two more codes that are commonly used by our Members and are also slated for deletion: 

• R05 - Cough
• R63.3 - Feeding Difficulties

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.

CMS is kicking off this compliance season with a bang—but even more changes are slated to come down the pipeline with the 2022 final rule. Keep your eyes on the blog for the latest and greatest info that you need to know.