New Patient (99202–99205): No visit within 3 years. Time/complexity drives code:
99202 = 15–29 min 99203 = 30–44 99204 = 45–59 99205 ≥ 60 min.

Established (99212–99215): Seen within 3 years.
99212 = 10–19 min 99213 = 20–29 99214 = 30–39 99215 ≥ 40 min.

Use –25 modifier for E/M + procedure same day.

Medical necessity: pain causing measurable loss (ROM, ADL, work), imaging correlation, and failure of conservative care ≥ 6 weeks (PT, NSAIDs).
Example: persistent L5 radiculopathy despite PT → qualifies for ESI (meets medical necessity).

M54. 5 code replacements [ AS OF 10/1/2021]  M54.5 = not billable (unspecified LBP).

• 2- (lumbago due to intervertebral disc displacement)

• 4- (lumbago with sciatica)

• 50  (low back pain)  (low back pain, unspecified)

• 51 (vertebrogenic low back pain)

• 59 (other low back pain)

• 012 (low back strain)

Common Modifiers

–25 = Significant, separately identifiable E/M service (E/M + procedure same day).
–59 = Distinct procedural service (two unrelated procedures same day).
–RT = Right side (used for paired organs or limbs).
–LT = Left side (used for paired organs or limbs).
–50 = Bilateral procedure (same procedure performed on both sides).
–24 = Unrelated E/M by the same physician during a post-op period.
–26 = Professional component only (used when interpreting diagnostics or radiology).
–TC = Technical component only (used when performing diagnostics without interpretation).
–76 = Repeat procedure by the same provider (redo injection or test).
–77 = Repeat procedure by a different provider (e.g., same-day ultrasound by another physician).

⚠️ Non-Billable / Unspecified Pain Codes
M54.5 low back pain unspecified, M54.9 dorsalgia unspecified, M25.50 joint pain unspecified site, M79.60 pain in limb unspecified, M79.1 myalgia unspecified, R52 pain unspecified, M54.89 other dorsalgia, M53.80 spinal disorder unspecified.

✅ Use site-specific, laterality-defined, and etiologic codes instead (e.g., M54.16 lumbar radiculopathy, M25.561 right knee pain, M79.18 myofascial pain).

BILLING/CODING REF:

1. Centers for Medicare & Medicaid Services (CMS) 👉 https://www.cms.gov/medicare/coding
   Official source for CPT/HCPCS, ICD-10, NCCI edits, and MUEs. Primary compliance reference for all payers.

2. American Medical Association (AMA) – CPT® Code Search 👉 https://www.ama-assn.org/practice-management/cpt
   Authoritative CPT coding resource with detailed procedure descriptions and guidelines.

3. American Academy of Professional Coders (AAPC) 👉 https://www.aapc.com/codes/
   Comprehensive tool for ICD-10-CM, CPT, HCPCS lookups with modifier guidance and audit tips.

4. National Correct Coding Initiative (NCCI) Edits 👉 https://www.cms.gov/medicare/payment/ncci
   Identifies code pairs that cannot be billed together; essential for avoiding denials.

5. Find-A-Code 👉 https://www.findacode.com/ All-in-one coding library with payer-specific policies, LCD/NCD links, modifiers, and RVUs.
   
   

🩺 DME Billing Documentation Example:
Include diagnosis supporting medical necessity, objective findings (instability, weakness, post-surgical protection), functional impact (impaired ambulation or ADL), failed conservative care, and physician order specifying brace type, side, purpose, and duration (e.g., “L0637 LSO for chronic L5-S1 instability needing rigid support 6 weeks”).

💡 Tip: Link diagnosis directly to DME HCPCS code on the claim — see:

• CMS DMEPOS Billing & Coding Guidance → https://www.cms.gov/medicare/payment/dmepos

• Noridian LCD & Policy Articles for Orthoses → https://med.noridianmedicare.com/web/jadme/policies/lcd
  
  

Head / Face

ICD-10:
G50.1 Atypical facial pain R51 Cervicogenic/suboccipital HA G44.009 Cluster HA M54.81 Occipital neuralgia G97.1 Post-dural puncture HA M26.60 TMJ disorder G44.209 Tension-type HA G50.0 Trigeminal neuralgia

CPT:
64405 Greater occipital NB 64450 Lesser occipital NB 64400 Trigeminal NB 64505 SPG block 20605 TMJ inj 64615 Botox migraine 64616 Botox neck J0585 Botox A J0587 Botox B 77002 Fluoro (non-spinal) if not bundled

Cervical Spine
M54.2 Cervicalgia, neck pain from strain, facet, or disc origin, non-radiating.
M50.21 High cervical disc hern C2–3, upper neck pain, suboccipital.
M50.22 Mid cervical disc hern C3–C7, arm radic pain, paresthesia.
M50.23 C7–T1 disc hern, lower neck, shoulder-hand radiation.
M54.12 Cervical radiculopathy, radiating pain to arm, sensory/motor deficit.
M54.02 Cervical facet syndrome, axial pain, worse rotation/extension.

Thoracic Spine
M54.6 Thoracalgia, mid-back pain from disc, strain, or facet origin.
M51.24 Thoracic disc hern, T1–T9, mid-back or intercostal pain.
M51.25 Thoracolumbar disc hern T8–L1, flank or upper-lumbar radiation.
M51.34 DDD thoracic, degenerative narrowing, stiffness, dull ache.
M54.14 Thoracic radiculopathy, bandlike pain along rib or flank.
M54.04 Thoracic facet syndrome, localized tenderness, pain on extension.

Lumbar Spine
M54.50 Lumbago, lower-back pain from disc, strain, or facet origin. NOT M54.50
M51.26 Lumbar disc hern L1–L5, back pain radiating to thigh/leg.
M51.27 Lumbosacral disc hern L5–S1, sciatica to foot or toes.
M51.36 DDD lumbar, disc height loss, stiffness, chronic ache.
M54.16 Lumbar radiculopathy, shooting pain along L1–L5 dermatomes.
M54.17 Lumbosacral radiculopathy, radiating pain into posterior thigh/foot.
M54.3 Sciatica, nerve root irritation causing sharp leg pain.
M54.31 Sciatica right side, radiating pain right buttock to calf.
M54.32 Sciatica left side, radiating pain left buttock to calf.
M54.06 Lumbar facet syndrome, axial pain, worse with extension or standing.

Sacrum / SI Joint / Coccyx
M46.1 Sacroiliitis, inflammatory SI joint pain, morning stiffness.
M53.3 Coccydynia, tailbone pain, worse sitting or pressure.
M47.818 Sacral spondylosis, degenerative SI or sacral joints.
M54.89 Other dorsalgia, generalized sacral discomfort.
M53.2X7 SI joint dysfunction, pain over posterior pelvis with sitting/standing.
S33.6XXA Sprain SI ligaments, acute posterior pelvic pain after strain.
S33.8XXA Other sacral sprain, traumatic SI irritation.
M54.18 Sacral radiculopathy, pain radiating from sacral roots into buttock/perineum.
M96.1 Post-laminectomy syndrome, chronic pain post spinal surgery, sacral region.

Cervical Spine (Neck)

ICD-10:
M54.2 Cervicalgia, neck pain from strain, facet, or disc origin, non-radiating. M50.21 high cervical disc hern C2–3, upper neck pain, suboccipital.

M50.22 mid cervical disc hern C3–C7, radic arm pain, paresthesia. M50.23 C7–T1 disc hern, lower neck, shoulder-hand radiation. 

M50.31 DDD high (C2–C3), disc dehydration, stiffness, axial pain. M50.32 DDD mid (C3–C7), osteophytes, foraminal narrowing, radic pain. M50.33 DDD cervicothoracic (C7–T1), junctional degeneration, neck–shoulder fatigue.  

M54.02 Facet syn 

M43.6 Torticollis M96.1 Post-lam syn M54.12 Cerv radic M48.02 Stenosis M47.812 Spond w/o myelo M47.22 w radic S13.4XXA/D Sprain S16.1XXA/D Strain

CPT:
62321 Interlam ESI C/T 64479 TF ESI C/T 1st 64480 Add’l 64490-64492 Facet MB block 64633/64634 RFA facet 64510 Stellate block 20552-20553 TPI
Imaging: 77003 Fluoro (spinal) only when not bundled.

Bracing:
L0120 Soft foam collar L0170 Semi-rigid plastic L0180 Custom rigid collar

Thoracic Spine

ICD-10:
M54.6 Pain thoracic M51.24–.25 Disc hern T/TL M51.34–.35 DDD M48.04 Stenosis M47.814 Spond w/o myelo M47.14 w myelo M96.1 Post-lam syn

CPT:
62321 Interlam ESI T 64479/64480 TF ESI T 64490-64492 Facet MB block 64633/64634 RFA facet 22513 Kypho T 1st +22515 Add’l 64520 Thor symp block 64530 Celiac plexus block
Imaging: 77003 Fluoro (spinal) for non-bundled sympathetic/plexus blocks.

Bracing:
L0637 TLSO rigid prefab L1005 TLSO Jewett hyper-ext L0456 TLSO rigid shell custom

Lumbar Spine / Back

ICD-10:
M54.50 LBP M51.26–.27 Disc hern L/LS M51.36–.37 DDD M48.061/.062 Stenosis w/wo claud M54.16/.17 Radic M47.816/.817 Spond M43.16/.17 Spondylolisthesis M62.830 Spasm back mm

CPT:
62323 Interlam ESI L/S 64483 TF ESI 1st 64484 Add’l 64493-64495 Facet MB block 64635/64636 RFA facet 27096 SI inj (+77003) 64517 Sup hypogastric (+77003) 64520 Ganglion impar (+77003) 63650 SCS trial 63655 SCS perm
Imaging: 77003 Fluoro (spinal) for SI/sympathetic only.

Bracing:
L0631 Lumbar rigid panel L0637 LSO rigid custom L0650 LSO rigid prefab L0627 Lumbar flex-rigid L0456 TLSO rigid shell

Sacrum / SI Joint / Pelvis

ICD-10:
M46.1 Sacroiliitis M53.3 Coccydynia M47.818 Sacral spond G57.01/02 Piriformis syn M70.61/62 Troch bursitis M70.71/72 Ischial bursitis M76.01/02 Gluteal tendinitis

CPT:
27096 SI inj (+77003) 64450 Lat branch NB (+77003) 64640 RFA periph n (sacral) 20552 Piriformis TPI 64445 Sciatic NB 20610 Hip inj (+77002)

Imaging: 77003 Fluoro (spinal SI); 77002 Fluoro (non-spinal hip).

Shoulder

ICD-10:
M25.511/512 Pain shoulder M75.01/02 Frozen M75.21/22 Bicipital M75.51/52 Bursitis M75.41/42 Impingement S43.431A/432A SLAP M19.011-.032 OA shoulder M19.111/112 AC OA S46.011X/012X RC tear

CPT:
20610 Major joint inj (+77002 if fluoro) 23350 Arthrogram (+77002) 64415 Brachial plexus NB 64418 Suprascapular NB 64450 Axillary NB 64614 Botox shoulder mm
Bracing: L3670 Clavicle strap A4565 Sling

Elbow

ICD-10:
M77.11/12 Lat epicondylitis M77.01/02 Medial epicondylitis M70.21/22 Olecranon bursitis G56.21/22 Ulnar neuropathy G56.11/12 Median lesion G56.31/32 Radial palsy

CPT:
20605 Joint inj 20550 Tendon sheath inj 20526 Cubital tunnel inj 64450 Ulnar NB
Bracing: L3702 Elbow hinged

Wrist / Hand

ICD-10:
G56.01/02 Carpal tunnel G56.41/42 Ulnar tunnel M65.4 De Quervain’s M65.30-.37 Trigger finger M19.031/032 OA wrist M19.041/042 OA hand

CPT:
20600 Small joint inj 20550 Tendon sheath inj 20551 Tendon origin/insertion 20526 Carpal tunnel inj 96372 Therapeutic inj (IM/SC)
Bracing: L3908 Cock-up wrist L3916 Adj WHO L3923 Thumb spica OTS L3924 Custom thumb spica

Knee

ICD-10:
M17.11/12 OA knee M25.561/562 Pain knee M22.41/42 Chondromalacia S83.24xA Meniscus tear M76.51/52 Patellar tendinitis

CPT:
20610 Major joint inj (+77002) 64450 Genicular NB (×3) 64640 Genicular RFA (×3) 64447 Femoral NB 64445 Sciatic NB
Bracing / DME:
L1820 Elastic hinged L1830 Immobilizer L1832 Hinged custom L1833 Hinged OTS L1843 Unloader custom L1851 Unloader OTS L1845 Ligament custom L1852 Ligament OTS E0935 CPM E1811 Static stretch

Ankle / Foot

ICD-10:
M76.61/62 Achilles tendinitis M72.2 Plantar fasciitis M77.41/42 Metatarsalgia G57.61/62 Morton’s neuroma M25.571/572 Pain ankle/foot G57.51/52 Tarsal tunnel

CPT:
20600 Small joint inj 20605 Intermediate joint inj 64455 Morton’s NB 64450 Tibial NB 64450 Saphenous NB
Bracing / DME:
L1902 Lace-up ankle L1906 Semi-rigid stirrup L4361 Pneumatic boot OTS L4360 Custom boot L4387 Non-pneumatic OTS L4386 Non-pneumatic custom

CRPS / Pain Syndromes (Upper & Lower)

ICD-10:
G90.521-.523 CRPS I lower G57.71-.72 CRPS II lower G90.511-.513 CRPS I upper G56.41/42 CRPS II upper

CPT:
64520 Lumbar symp block 64510 Stellate block 64415 Brachial plexus NB 64450 Periph NB 64590 PNS electrode insert (if indicated)
Imaging: 77003 Fluoro (spinal sympathetic) if not bundled

Electrodiagnostic Testing (EMG/NCS)

CPT:
95905 NCS 1-2 95907 1-2 95908 3-4 95909 5-6 95910 7-8 95911 9-10 95912 11-12 95913 ≥13 95900 Motor NCS 95903 Motor NCS +F-wave 95904 Sensory NCS 95934 H-reflex soleus 95936 H-reflex other 95933 Blink reflex 95885 EMG limited 95886 EMG complete 95887 EMG non-extremity 95860-95864 EMG 1-4 extremities 95867-95868 Cranial EMG
Modifiers: Use -26 for professional component if equipment owned by facility.

Therapy & Modalities

CPT:
97010 Hot/cold pack 97012 Traction 97024 Diathermy 97032 E-stim manual G0283 E-stim unattended (TENS) 97035 Ultrasound 97110 Ther ex 97140 Manual therapy 97530 Therapeutic activity 97535 Self-care/home mgmt 97810/97811 Acupuncture (no/with stim) 97813/97814 Acupuncture with stim (initial/follow-up)
OMT: 98925-98929 OMT 1-10 body regions

Injectable Medications (J-codes)

Steroids & Analgesics:
J1100 Dexamethasone 1 mg J0702 Betamethasone comp 3 mg J0704 Betamethasone 4 mg J1030 Methylpred 40 mg J1040 Methylpred 80 mg J3301 Triamcinolone 10 mg J1885 Ketorolac 15 mg J2250 Midazolam 1 mg J3010 Fentanyl 0.1 mg J1200 Diphenhydramine 50 mg J2800 Methocarbamol 1 g J0585 Botulinum A J0587 Botulinum B
Viscosupplement: J7325 Hyaluronan per dose
Contrast: Q9967 Omnipaque 300 mg/ml Q9966 Omnipaque 240 mg/ml

Cannabis-Related ICD-10 Codes

F12.90 Cannabis use, unspecified uncomplicated
F12.10 Cannabis abuse, uncomplicated
F12.20 Cannabis dependence, uncomplicated
R11.16 Cannabis hyperemesis syndrome
Z79.899 Other long-term (current) drug therapy
Z91.89 Other specified personal risk factor

Fluoroscopy Guidelines

77002 = Non-spinal fluoro (TMJ, hip, knee, shoulder, peripheral NB)
77003 = Spinal fluoro (SI, sympathetic, plexus, neurolytic)
Not billable with ESI, facet, or RFA codes that already include imaging.

Non-Billable / Self-Pay Notes

• Self-pay braces: Certain over-the-counter or flexible lumbar supports (elastic, non-rigid) are non-billable; HCPCS such as L0626, L0628, L0629 often considered “comfort” devices.

• Knee braces: Basic neoprene sleeves or elastic supports (non-hinged) are non-covered; codes without rigid components generally self-pay.

• TENS units: May be self-pay unless prescribed for chronic pain with documentation (E0720 single channel, E0730 dual channel).

• Lidocaine patches: Typically OTC/self-pay unless compounded and billed as J2001 (injection); topical forms (5 % patch) are not DME-billable under Medicare Part B.