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2025 ICD-10-CM code S39.012

Strain of muscle, fascia, and tendon of the lower back.

Accurate coding requires detailed documentation supporting the diagnosis of a strain, as opposed to a sprain, fracture, or other lower back condition.Use additional codes to specify any open wounds, retained foreign bodies, or complications.

Modifiers may be applicable based on specific circumstances of service, such as the location of service or the use of anesthesia. Consult the most recent modifier guidelines for more details.

Medical necessity for the diagnosis and treatment of lower back strain is established when a patient presents with symptoms consistent with the condition, and the clinical examination and/or imaging findings support the diagnosis.Treatment is medically necessary to alleviate pain, restore function, and prevent further injury or disability.

Diagnosis and treatment of lower back strain by a physician or other qualified healthcare provider. This may include obtaining a patient history, performing a physical examination, ordering and interpreting imaging studies, prescribing medications, and recommending physical therapy or other rehabilitative interventions.

IMPORTANT:This code is an alternative to the now-deleted M54.5 (low back pain) due to its increased specificity. Other codes that might be applicable depending on the specific diagnosis include 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), and M54.59 (other low back pain).Using this code alongside codes from the M54.5 family may result in NCCI edits.

In simple words: A pulled muscle in the lower back. This happens when the muscles or tendons in your lower back are stretched too far or torn.It causes pain and may make it hard to move around. Doctors diagnose this by talking to you, examining you, and sometimes using imaging tests like X-rays. Treatment might involve pain relievers, rest, and physical therapy.

This code signifies a strain affecting the muscles, fascia, and tendons of the lower back.It involves overstretching or tearing of these tissues in the lumbar region, resulting in pain and potential debility.Diagnosis involves patient history, physical examination to assess tissue damage, and imaging (X-rays, CT, MRI) to rule out fractures or determine tear severity. Treatment may include analgesics, muscle relaxants, NSAIDs, bracing/splinting, and physical therapy.

Example 1: A 45-year-old construction worker experiences sudden lower back pain after lifting heavy materials. Physical examination reveals muscle spasms and tenderness.Imaging is negative for fracture. Diagnosis: S39.012., A 60-year-old woman reports gradual onset of lower back pain over several weeks, worsening with prolonged standing.Physical examination reveals muscle weakness and restricted range of motion.Imaging shows no fracture or disc herniation. Diagnosis: S39.012., A 28-year-old athlete sustains a lower back strain during a sporting event.Immediate pain and swelling are noted.Physical examination confirms muscle tenderness.Imaging is negative for any fracture. Diagnosis: S39.012.

Detailed patient history including mechanism of injury, onset and nature of pain, associated symptoms (muscle spasms, weakness, etc.), relevant past medical history.Physical examination findings including range of motion, muscle strength, palpation for tenderness. Imaging reports (X-ray, CT, MRI) if performed. Treatment plan including medications, physical therapy interventions, and patient education.

** This code is for muscle, fascia, and tendon strain, not for sprain of the joints and ligaments of the lumbar spine and pelvis (coded elsewhere).

** Only Enterprise users with EHR integration can access case-specific answers. Click here to request access.

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