LUMBAR PAIN
LUMBAR PAIN
ICD-10: S39.012A (Strain of lumbar region), M54.5 (Low back pain)
S: Dull ache after rear-end MVA, worsens with movement.
O: βflexion, TTP lumbar paraspinals, neg neuro.
A: Acute lumbar strain, axial back pain.
P: PT, core stabilization, Alpha-Stim E0730, NSAIDs.
π Forms: CMS-1500, narrative, causation letter.
ICD-10: M54.16 (Radiculopathy, lumbar region, left), G57.12 (Left sciatica)
S: Radiating left leg pain, numbness post-MVA.
O: +SLR L>R, βsensation L5 dermatomes.
A: Left lumbosacral radiculopathy.
P: MRI lumbar spine, transforaminal ESI 64483, Alpha-Stim, McKenzie extension.
π Forms: Imaging order, narrative, LOMN for injection.
ICD-10: M53.3 (Sacroiliac joint dysfunction), M54.30 (Sciatica, unspecified side)
S: Low back & buttock pain post side-impact.
O: +FABER, SI joint TTP.
A: Post-traumatic SI joint inflammation.
P: SI joint injection 27096, Alpha-Stim, pelvic stabilization belt.
π Forms: CMS-1500, LOMN, med necessity statement.
ICD-10: M51.26 (Other intervertebral disc displacement, lumbar region), M54.5
S: Shooting pain down right leg after crash.
O: βreflexes, +SLR, antalgic gait.
A: Herniated lumbar disc with radiculopathy.
P: MRI, interlaminar ESI 62323, Alpha-Stim, consider surgical eval.
π Forms: Imaging, narrative, PIP certification (FL).
ICD-10: M79.1 (Myalgia), M62.830 (Muscle spasm of back)
S: Deep lumbar ache with tightness.
O: Paraspinal hypertonicity, βflexion, normal neuro.
A: Myofascial pain with spasm.
P: Trigger point injection 20552, PT, E0730, heat therapy.
π Forms: SOAP note, LOMN (Alpha-Stim, TPI), proof of loss.
ICD-10: M54.5, M47.816 (Facet arthropathy, lumbar region)
S: Pain with extension and twisting post-MVA.
O: +Kempβs, βextension, neg SLR.
A: Multilevel lumbar facet pain.
P: Medial branch blocks 64493β64495, Lumbar RFA 64635β64636, Alpha-Stim.
π Forms: LOMN, narrative, CPT log.
ICD-10: S33.6XXA (Sprain of SI joint), M25.559 (Pelvic region pain)
S: Posterior pelvic pain, worse on stairs.
O: +Thigh thrust, gait asymmetry.
A: SI sprain with mechanical instability.
P: Pelvic brace L0621, SI RFA 64640, Alpha-Stim.
π Forms: DME justification, med necessity letter, CMS-1500.
ICD-10: M47.816 (Other spondylosis, lumbar), M54.5
S: Chronic low back stiffness aggravated by crash.
O: βROM, tight extensors, neg neuro.
A: Degenerative changes, exacerbated.
P: MRI, PT, Alpha-Stim, consider facet RFA, bracing.
π Forms: Imaging, LOMN, CMS-1500.
ICD-10: M53.2X6 (Instability, lumbar region), M54.5
S: Pain standing/sitting, feels "shaky."
O: βpain on axial load, flex/ext instability.
A: Post-traumatic lumbar instability.
P: Lumbosacral orthosis L0637, PT, Alpha-Stim, monitor for fusion need.
π Forms: LOMN, brace fitting report, narrative.
ICD-10: M48.06 (Spinal stenosis, lumbar), G57.10 (Lumbosacral plexus disorder)
S: Leg heaviness, low back tightness when walking.
O: βLE strength, improved w/flexion.
A: Lumbar stenosis with claudication.
P: Interlaminar ESI 62323, Alpha-Stim, neurosurg referral, core rehab.
π Forms: Causation, PIP packet, imaging request.
S: Throbbing HA, photophobia.
O: Normal neuro exam.
A: Migraine.
P: Triptan, caffeine avoidance, occipital block 64405 PRN.
S: Visual aura β HA.
O: Normal exam.
A: Migraine w/ aura.
P: Prophylaxis + abortive meds, 64405 if refractory.
S: Band-like pressure, stress.
O: Normal neuro.
A: Tension HA.
P: NSAIDs, muscle relaxants, stress mgmt.
S: Unilateral orbital pain, tearing.
O: Lacrimation noted.
A: Cluster HA.
P: Oxygen, SPG block 64505, triptan nasal.
S: Daily dull HA, med overuse.
O: Normal.
A: MOH.
P: Wean off analgesics, bridge w/ steroids, consider 64405.
S: Occipital pain, worsens w/ neck motion.
O: βROM, facet TTP.
A: Cervicogenic HA.
P: PT, posture, occipital block 64405.
S: Facial pressure, congestion.
O: Maxillary tenderness.
A: Acute sinusitis.
P: Amoxicillin, decongestants, no injection.
S: Jaw clicking, temple pain.
O: TTP masseter.
A: TMJ headache.
P: Night guard, PT, TPI 20552.
S: Sharp pain, posterior head.
O: Occipital nerve TTP.
A: Occipital neuralgia.
P: Occipital nerve block 64405, PT, gabapentin.
S: HA post-MVA.
O: Normal CT, photophobia.
A: Post-traumatic HA.
P: Rest, NSAID, screen for PCS.
S: Neck pain post whiplash.
O: Paraspinal TTP.
A: Cervical strain.
P: PT, NSAIDs, TPI 20552, brace L0172.
S: Neck + arm pain, numbness.
O: +Spurling, βreflex.
A: C6 radiculopathy.
P: TFESI 64479β64480, traction, MRI.
S: Stiffness, grinding, βmotion.
O: βROM, facet TTP.
A: DDD cervical.
P: PT, facet block 64490, brace L0180.
S: Pain from neck β occiput.
O: βC-spine ROM.
A: Cervicogenic HA.
P: PT, posture, occipital block 64405.
S: Local neck ache, trigger bands.
O: TTP upper traps.
A: Myofascial neck pain.
P: PT, TPI 20552, stretch.
S: Neck pain post-MVA.
O: Tender SCM, βflexion.
A: Whiplash.
P: Ice, PT, brace L0172.
S: Neck pain + hand numbness.
O: βgrip, wide gait.
A: Cervical stenosis.
P: LESI 62321, MRI, refer neuro.
S: Chronic neck pain post-ACDF.
O: βROM, facet loading.
A: Post-surgical syndrome.
P: PT, facet RFA 64633, imaging.
S: Local pain, worse rotation.
O: +facet loading.
A: Facet arthropathy.
P: MBB 64490, RFA 64633, posture PT.
S: Neck/arm pain, numbness.
O: +Roos, βpulse w/ abduction.
A: TOS.
P: Postural PT, neuro referral, EMG.
S: Dull, daily headaches after MVA.
O: βscalp TTP, slowed recall.
A: Post-traumatic headache, unspecified cephalgia.
P: Alpha-Stim E0730, cognitive rest, PT.
S: Shock-like pain at occipital base.
O: +Tinelβs at greater occipital nerve.
A: Occipital neuralgia, cervicogenic headache.
P: 64405 occipital nerve block, PT, Alpha-Stim.
S: Right-sided orbital headache from neck.
O: βcervical ROM, paraspinal TTP.
A: Cervicogenic headache, cervicalgia.
P: 64490 MBB, Alpha-Stim, cervical PT.
S: Cognitive fog and headache post-MVA.
O: Impaired delayed recall, photophobia.
A: Concussion w/o LOC, unspecified headache.
P: Neuro eval, E0730, cognitive rest.
S: Head tightness, worse w/stress.
O: βcervical tension, +trapezius trigger points.
A: Tension headache, cervical myalgia.
P: PT, Alpha-Stim, posture training.
S: Pulsating pain, nausea, photophobia.
O: +light sensitivity, normal exam.
A: Migraine, non-intractable.
P: Abortive meds, Alpha-Stim, trigger control.
S: Pain over cheek after airbag deployment.
O: +zygomatic TTP.
A: Post-traumatic facial pain.
P: CT scan, rest, E0730.
S: Jaw clicks, headache w/chewing.
O: βjaw opening, TMJ TTP.
A: TMJ arthralgia with myalgia.
P: Bite guard, PT, Alpha-Stim.
S: Headache triggered by screens/lights.
O: Visual fatigue, no neuro deficit.
A: Visual-related tension headache.
P: Alpha-Stim, eye consult, ergonomics.
S: Occipital headache post rear-end crash.
O: βROM, upper cervical TTP.
A: Whiplash with secondary headache.
P: L0172 collar, PT, Alpha-Stim.
S: Neck pain/stiffness post-MVA.
O: βflexion/extension, muscle TTP.
A: Cervical strain, cervicalgia.
P: PT, L0172 brace, Alpha-Stim.
S: Right arm numbness, neck pain.
O: βreflexes, +Spurlingβs.
A: Cervical radiculopathy, nerve root impingement.
P: MRI, ESI 62320, Alpha-Stim, PT.
S: Muscle tightness, tension.
O: +jump sign over trap.
A: Cervical myofascial pain, muscle spasm.
P: Trigger point injection 20552, Alpha-Stim, PT.
S: Pain rotating head, worse with extension.
O: +facet TTP, βcervical extension.
A: Cervical facet arthritis.
P: MBB 64490-64492, Alpha-Stim, PT.
S: Neck looseness, "clunky" sensation.
O: +hypermobility, instability end-range.
A: Cervical instability post trauma.
P: L0172 collar, PT, Alpha-Stim.
S: Vertigo with neck motion.
O: Normal neuro, cervical TTP.
A: Cervicogenic dizziness.
P: Vestibular PT, Alpha-Stim.
S: Sharp shooting pain over skull base.
O: +Tinel's over GON.
A: Occipital neuralgia.
P: 64405 block, Alpha-Stim E0730 , PT.
S: Neck/arm pain post-crash.
O: βstrength, dermatomal numbness.
A: Cervical herniated disc.
P: MRI, ESI 62320, Alpha-Stim E0730 , PT.
S: Pain turning head.
O: SCM TTP, βrotation.
A: SCM strain, myofascial pain.
P: Stretching, manual therapy, Alpha-Stim E0730 .
S: Persistent pain, poor focus.
O: βROM, dull affect.
A: Chronic neck pain with PCS.
P: Alpha-Stim E0730 , neuropsych, PT.
S: Chronic right knee pain, worse walking.
O: βROM, crepitus.
A: OA with knee pain.
P: 20610 RT, KneeWell E1399, PT, brace L1833.
Alpha-Stim optional (E0730).
S: Locking left knee, medial pain.
O: +McMurray.
A: Medial meniscus tear.
P: MRI, KneeWell ROM, possible arthroscopy 29880.
Alpha-Stim not indicated.
S: Anterior knee pain stairs, both sides.
O: +Grind, maltracking.
A: Bilateral PFPS.
P: VMO training, PT 97110, KneeWell E1399, Alpha-Stim E0730 pre-exercise.
S: Medial pain after twist.
O: +Valgus laxity.
A: MCL sprain.
P: PT, brace L1810, KneeWell, Alpha-Stim E0730 for discomfort.
S: Instability, right knee pain.
O: +Lachman, mild effusion.
A: ACL partial tear.
P: MRI, brace L1850, NM re-ed with KneeWell.
S: Morning stiffness both knees.
O: Swelling, βROM.
A: RA flare.
P: 20610 bilateral, labs, Alpha-Stim E0730, refer rheum.
S: Swelling over kneecap.
O: TTP prepatellar.
A: Bursitis.
P: 20610 RT, compression, rest.
No device needed.
S: Pain, stiffness after scope.
O: βflexion <100Β°.
A: Post-op stiffness.
P: PT 97110, KneeWell E1399, Alpha-Stim E0730, brace optional.
S: Jumping pain over tendon.
O: TTP inferior pole.
A: Patellar tendinitis.
P: Eccentric PT, Alpha-Stim E0730, US 76882 if chronic.
S: Swelling, stiffness.
O: +Ballottement, βflexion.
A: Effusion.
P: 20610 LT, fluid eval, KneeWell ROM, PT.
S: Pain with grasping post-MVA.
O: TTP at CMC joint, βopposition.
A: Right thumb tendinitis and joint pain.
P: Thumbster brace (L3923), 20552 trigger point inj, Alpha-Stim (E0730), PT/OT, topical NSAID.
S: Pain lifting objects after workplace fall.
O: βROM, dorsal wrist TTP.
A: Wrist sprain with joint pain.
P: Apollo Universal Wrist (L3908), PT, Alpha-Stim (E0730), rest, naproxen.
S: Recurrent ankle rollouts, worse post-accident.
O: Ligament laxity, mild edema.
A: Chronic ankle instability with acute sprain.
P: Ankle Lace-Up w/Tibia Strap (L1902), proprioceptive PT, Alpha-Stim (E0730), topical diclofenac.
S: Pain on first step in the morning.
O: TTP at medial calcaneus.
A: Plantar fasciitis.
P: PFS Night Splint (L4398), Alpha-Stim (E0730), plantar/calf stretching, PT, topical NSAID.
S: Pain and bruising after twisting ankle at job site.
O: TTP lateral ligaments, limited ROM.
A: Lateral ankle sprain.
P: Air Stirrup Plus (L4350), PT, Alpha-Stim (E0730), naproxen, rest.
S: Pain over arch after prolonged standing.
O: TTP forefoot, +Mortonβs test.
A: Metatarsalgia.
P: Foot orthotics, Alpha-Stim (E0730), stretching, 20552 trigger point inj PRN, PT.
S: Knee swelling after dashboard impact in MVA.
O: βROM, +ballottement.
A: Left knee effusion.
P: 20610 aspiration/inj, KneeWell (E1399), Alpha-Stim (E0730), PT, topical NSAID.
S: Pinch and grip pain at work.
O: +grind test, βgrip strength.
A: CMC arthritis.
P: Thumbster brace (L3923), 20552 injection PRN, Alpha-Stim (E0730), joint protection PT, topical NSAID.
When treating patients injured in a motor vehicle accident, proper documentation ensures medical necessity, facilitates reimbursement, and supports legal claims. Here's what is typically required:
Chief complaint, mechanism of injury, objective findings (ROM, neuro, imaging), diagnosis (ICD-10), and treatment plan (including CPT/HCPCS codes).
Should specify MVA as the cause and describe functional limitations.
Brief narrative linking the patientβs current condition directly to the motor vehicle collision (e.g., βInjury is consistent with the mechanism of a rear-end collision and symptoms began immediately after the incident.β).
Expanded clinical summary of the patientβs injury, physical findings, treatment response, and prognosis. Often required by insurers and attorneys.
Should include duration, severity, progress, and limitations.
Must document necessity for treatments, especially DME (bracing), electrotherapy (Alpha-Stim E0730), and injections (20610).
Forms may include Letters of Medical Necessity and physician attestation.
Includes CMS-1500 form, itemized statement, diagnostic codes, and any supporting documentation like imaging reports or operative notes.
In Florida, also submit PIP Attestation if within 14-day window.
Type
Florida (PIP State)
Georgia (Tort State)
Claim Form
CMS-1500, PIP Form, Attending Provider Form
CMS-1500, narrative, patient statement
Medical Narrative
Strongly recommended (often requested)
Required for reimbursement or legal use
Proof of Loss
Mandatory with bracing/DME
Required for insurers upon request
Imaging Reports
MRI, X-ray reports (if performed)
Same
ICD-10: M75.51 (Bursitis), M25.511 (Shoulder joint pain, right)
S: Right shoulder pain post rear-end MVA.
O: βROM, +Neer.
A: Subacromial bursitis, joint pain.
P: 20610 inj, shoulder sling L3660, PT, Alpha-Stim E0730.
π Forms: CMS-1500, PIP form, narrative.
ICD-10: S16.1XXA (Strain of neck muscle), M54.2 (Cervicalgia)
S: Neck tightness, headache after MVA.
O: βROM, TTP paraspinals.
A: Cervical strain, chronic neck pain.
P: L0172 collar, PT, Alpha-Stim, heat.
π Forms: Causation letter, SOAP, proof of loss.
ICD-10: M25.462 (Effusion, left), M25.562 (Pain in left knee)
S: Swelling post dashboard trauma.
O: βflexion, +ballottement.
A: Effusion, post-traumatic pain.
P: 20610 inj, KneeWell E1399, PT, E0730.
π Forms: Narrative, imaging, CMS-1500.
ICD-10: S93.401A (Sprain of right ankle), M25.571 (Ankle pain, right)
S: Pain rolling foot during crash.
O: TTP ATFL, ecchymosis.
A: Ankle sprain, lateral pain.
P: L4350 brace, rest, PT, Alpha-Stim E0730.
π Forms: CMS-1500, injury statement, LOMN (brace).
ICD-10: S39.012A (Strain of lumbar region), M54.5 (Low back pain)
S: Back pain post rear-end crash.
O: βROM, TTP lumbar paraspinals.
A: Lumbar strain, axial pain.
P: Core rehab, PT, E0730, NSAIDs.
π Forms: Causation letter, SOAP, proof of loss.
ICD-10: S63.611A (Sprain, right thumb), M25.541 (Thumb joint pain, right)
S: Pain texting after impact.
O: +grind, CMC TTP.
A: Thumb sprain, CMC pain.
P: Thumbster L3923, 20600 inj PRN, E0730.
π Forms: PIP, physician note, CMS-1500.
ICD-10: M70.62 (Trochanteric bursitis, left), M25.552 (Hip pain, left)
S: Lateral hip pain from seatbelt.
O: TTP over trochanter.
A: Bursitis, post-MVA hip pain.
P: 20610 inj, stretching, Alpha-Stim E0730.
π Forms: Narrative, imaging, treatment plan.
ICD-10: S83.242A (Tear of medial meniscus, left), M25.562 (Pain in left knee)
S: Twisting injury stepping on brake.
O: +McMurray.
A: Meniscal tear, knee pain.
P: MRI, KneeWell, rehab, Alpha-Stim.
π Forms: Imaging order, CMS-1500, LOMN.
ICD-10: M72.2 (Plantar fasciitis), M79.674 (Pain in lower leg/foot, bilateral)
S: Heel pain post-braking force.
O: TTP medial calcaneus bilaterally.
A: Fasciitis, foot pain.
P: L4398 night splint, stretches, E0730.
π Forms: DME letter, claim summary.
ICD-10: M65.3 (Tendinitis, wrist), M25.531 (Wrist pain, right)
S: Pain gripping wheel post-impact.
O: TTP FCR, βwrist extension.
A: Tendonitis, joint pain.
P: L3908 wrist brace, PT, E0730, ice.
π Forms: LOMN, CMS-1500, injury note.
Low Back Pain β The most prevalent pain complaint in the U.S. About 39.0% of U.S. adults reported back pain in the past 3 months (2019 data)cdc.gov. This corresponds to roughly 100 million Americans experiencing low back pain in a given quarter.
Tension-Type Headaches β Very common βstressβ headaches. Approximately 40% of Americans have at least one tension-type headache each yearbellaireneurology.com. These episodic headaches are usually mild-to-moderate but can be frequent; overall, about 45 million Americans suffer recurring headaches each yearihateheadaches.org.
Neck Pain β Highly prevalent musculoskeletal pain in the U.S., often associated with back pain. Estimates suggest around 30%β50% of adults experience an episode of neck pain each yearphysio-pedia.com. Prevalence increases with age, and chronic neck pain (lasting β₯3 months) affects roughly 2β3% of U.S. adultsphysio-pedia.com.
Migraine Headache β Affects about 12% of Americans (more than 39 million people) β including 1 in 5 women and 1 in 16 menamericanmigrainefoundation.org. Migraines cause recurring moderate-to-severe head pain often with nausea and light sensitivity, and are a leading cause of disability in adults under 50.
Osteoarthritis β The most common joint disease, causing chronic pain in knees, hips, hands, etc. OA affects 32.5 million adults in the U.S.oaaction.unc.edu (roughly 13% of the adult population). In total, 53 million Americans (1 in 4 adults) have some form of doctor-diagnosed arthritis when including OA and other typesoaaction.unc.edu.
Neuropathic Pain β Nerve pain from conditions like diabetes, shingles, or nerve injuries. An estimated 10% of U.S. adults have chronic neuropathic painpharmacytimes.com. This equates to over 30 million Americans with neuropathic pain. (About 20 million Americans have peripheral neuropathy specificallypharmacytimes.com.)
Endometriosis (Chronic Pelvic Pain) β Endometriosis affects at least 11% of U.S. women, which is over 6.5 million women nationallywomenshealth.gov. It is a major cause of chronic pelvic pain and menstrual pain in women, often requiring surgery or hormone therapy for management.
Fibromyalgia β Roughly 4 million U.S. adults (about 2% of the adult population) have fibromyalgiaarchive.cdc.gov. It causes widespread body pain, fatigue, and tender points. Fibromyalgia is often underdiagnosed; patients are typically middle-aged and it disproportionately affects womenarchive.cdc.gov.
Cancer-Related Pain β Due to improved survival, millions live with a history of cancer and accompanying pain. Approximately 35% of U.S. cancer survivors have chronic pain, about 5.4 million individuals nationwidemountsinai.org. Cancer pain may result from tumors, nerve damage, or treatments like surgery and chemotherapymountsinai.org.
Rheumatoid Arthritis β About 1.5 million Americans have RApfizer.com, an autoimmune disease causing joint pain and swelling. RA can lead to chronic pain and joint deformities if untreated. (By comparison, less common forms of arthritis like lupus or gout each affect under 1% of the population.)
Low Back Pain (LBP) β Affects 619 million people globally as of 2020who.int. LBP is the leading cause of disability worldwide and most people experience it at least once in their liveswho.int.
Tension-Type Headache β The most common headache disorder, with an estimated 1.89 billion people (β24% of the world population) affected in 2016mdlinx.com. Overall, headache disorders (including tension-type and migraine) impacted about 40% of people worldwide (β3.1 billion) in 2021who.int.
Migraine Headache β A neurological pain disorder affecting roughly 1 in 7 adults globally (β14%), which translates to around 1 billion peoplewho.int. Migraine is a leading cause of disability, ranked third among neurological disorders worldwidewho.intwho.int.
Osteoarthritis (OA) β The most common form of arthritis, affecting 595 million people globally in 2020 (about 7.6% of the population)pubmed.ncbi.nlm.nih.gov. OA causes chronic joint pain (especially in knees, hips, and hands) and its global prevalence has more than doubled since 1990pubmed.ncbi.nlm.nih.gov.
Neuropathic Pain β Chronic neuropathic pain (from nerve damage, e.g. diabetic neuropathy, post-herpetic neuralgia) is estimated to affect 6.9β10% of the global populationthejournalofheadacheandpain.biomedcentral.com. This translates to on the order of hundreds of millions of people worldwide living with neuropathic painthejournalofheadacheandpain.biomedcentral.com.
Neck Pain β Approximately 206 million people globally had neck pain in 2021bmcmusculoskeletdisord.biomedcentral.com. Neck pain is among the top musculoskeletal causes of disability, with about 30β50% of individuals experiencing an episode of neck pain annuallyphysio-pedia.com.
Endometriosis (Chronic Pelvic Pain) β A gynecological condition causing pelvic and abdominal pain, affecting ~10% of women of reproductive age worldwide. That is about 190 million women globally living with endometriosiswho.int, which often leads to chronic pain and infertility.
Fibromyalgia β A chronic pain syndrome characterized by widespread musculoskeletal pain. It affects roughly 2% of the worldβs population (around 160 million people)moregooddays.com. Fibromyalgia is more common in women and often coexists with fatigue and sleep problemsmoregooddays.com.
Cancer-Related Pain β About 44.5% of all cancer patients worldwide experience pain, even with modern treatmentscris.maastrichtuniversity.nl. This includes pain from the cancer itself or its treatment. With roughly 19 million new cancer cases globally each year, tens of millions live with cancer pain at any timecris.maastrichtuniversity.nl.
Rheumatoid Arthritis (RA) β An autoimmune joint disease causing inflammatory pain. RA affected 18 million people worldwide in 2019who.int. Though a smaller population than osteoarthritis, RA often causes severe pain and disability in hands, wrists, and knees if not treatedwho.int.