Spondylosis w/o myelopathy or radiculopathy, lumbar region

This code signifies degenerative changes of the lumbar spine, specifically spondylosis, without evidence of spinal cord compression (myelopathy) or nerve root impingement (radiculopathy). It describes age-related wear and tear of the vertebral bodies and intervertebral discs in the lower back, often leading to bone spurs (osteophytes).

Apply this code when documentation confirms lumbar spondylosis as the primary diagnosis, and the physician explicitly rules out or does not document myelopathy or radiculopathy. It is appropriate for patients presenting with chronic low back pain attributed to degenerative changes, where neurological deficits are absent.

• Ensure physician documentation explicitly states "without myelopathy or radiculopathy" or clearly indicates the absence of these conditions.
• Do not use this code if any neurological symptoms (e.g., weakness, numbness, tingling, bowel/bladder dysfunction) are present and attributed to the spondylosis; instead, consider codes with myelopathy or radiculopathy.
• Always sequence this code after any acute conditions or injuries that may be co-occurring, unless the spondylosis is the primary reason for the encounter.