July 7, 2016
What diagnosis would you report for a patient with chronic low back pain due to degenerative disc disease (DDD) of the lumbar spine with radiculopathy.
The ICD-10-CM guidelines state that if the cause of the pain is known, assign a code for the underlying diagnosis, not the pain code. However, if the purpose of the encounter is to manage the pain rather than the underlying condition, then you should assign a pain code and sequence it first. Since the focus of the visit is pain management, chronic pain would be the first listed diagnosis. The primary diagnosis would be G89.29 (other chronic pain) followed by a secondary diagnosis of M51.16 (Intervertebral disc disorders with radiculopathy, lumbar region).
*This response is based on the best information available as of 07/07/16.