Spinal instabilities, lumbosacral region

This code signifies a loss of normal spinal stability in the lumbosacral region, leading to abnormal motion between vertebrae. This instability can result in pain, neurological symptoms, and functional impairment due to excessive movement or displacement of the vertebral bodies. It often indicates a biomechanical failure of the spinal column's supporting structures.

Apply this code when documentation clearly indicates lumbosacral spinal instability, such as spondylolisthesis (without specifying a traumatic cause), degenerative instability, or segmental hypermobility. Supporting documentation should include imaging reports (e.g., flexion/extension X-rays demonstrating abnormal translation or angulation) and physician notes detailing clinical findings consistent with instability.

• Ensure the documentation specifies "instability" in the lumbosacral region; do not assume instability from general back pain.
• Distinguish from spondylolisthesis with a traumatic cause (e.g., S33.1XXA for traumatic lumbosacral subluxation).
• Always code to the highest level of specificity, including the seventh character for the specific lumbosacral segment if documented.