Lumbosacral Strain ICD-10-CM Codes

Lumbosacral Strain ICD-10-CM Codes

Get accurate ICD-10 codes for lumbosacral strain with essential billing and clinical insights.

By Audrey Liz Perez on Aug 8, 2025.

Fact Checked by Ericka Pingol.

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What ICD-10 codes are used for lumbosacral strain?

Lumbosacral strain refers to the stretching or tearing of muscles, tendons, or ligaments in the lower back, specifically around the lumbar spine and sacrum. This type of strain is common cause of lower back pain and is often related to poor lifting techniques, overuse, or sudden movements. In ICD-10-CM coding, lumbosacral strains fall under various codes that indicate severity, causes, and healing stages.

Below are the ICD Codes for lumbosacral strain:

S39.012A: Strain of muscle, fascia and tendon of lower back, initial encounter

This is used for the initial diagnosis and treatment of lumbosacral strain. It denotes a strain affecting muscles, fascia, or tendons in the lower back.

S39.012D: Strain of muscle, fascia and tendon of lower back, subsequent encounter

This code is used during follow-up visits after the initial diagnosis when the patient continues to receive treatment or monitoring.

S39.012S: Strain of muscle, fascia and tendon of lower back, sequela

This is used when documenting long-term effects or complications from previously treated lumbosacral strain.

Which lumbosacral strain ICD codes are billable?

All the above codes are billable and specific. They provide enough detail for proper reimbursement and should be used based on the patient's current encounter type.

Clinical information

A lumbosacral strain involves the muscle, fascia, or tendons around the lumbar spine and sacrum. It is one of the most common causes of low back pain, especially among adults who perform heavy lifting or repetitive bending motions.

Symptoms include localized pain, stiffness, swelling, slight redness, skin warmth, pain in the back that gets worse with movement, and restricted movement in the lumbar region.

This condition may also coexist with discogenic back pain, intervertebral disc degeneration, or intervertebral disc displacement, particularly in chronic or recurrent cases. To diagnose lumbosacral strain, the practitioner will conduct a physical examination on the patient and have them undergo imaging tests like X-rays and MRIs. 

Treatment includes rest, physical therapy, NSAIDS, and in some cases, muscle relaxants. Severe cases may require more advanced intervention if the strain affects nearby ligaments or joints.

Synonyms include

  • Strain of tendon of lower back
  • Chronic lumbosacral strain
  • Muscle strain in the lower back
  • Soft tissue injury of lumbar spine
  • Low back strain
  • Lumbosacral strain
  • Injury of the muscle of the lower back
  • Injury of the tendon of the lower back
  • Dislocations, sprains, and strains involving the thorax with lower back and pelvis

Related ICD codes for lumbosacral strain

These may be used if other or more general conditions are documented:

  • M54.5 - Lower back pain
  • M51.26 - Other intervertebral disc displacement, lumbar region
  • M51.36 - Other intervertebral disc degeneration, lumbar region
  • M54.6 -  Ankylosing spondylitis of lumbar spine
  • S39.91XA - Unspecified injury of lower back, initial encounter

Commonly asked questions

You can use a lumbosacral strain ICD code when the patient is experiencing the symptom, and you have identified whether it’s an initial encounter, subsequent encounter, or sequela.

Yes, lumbosacral strain diagnosis codes are billable, particular ones.

Common treatments include medication, therapy, and rest, all of which help the patient manage and treat their pain.

Related ICDs

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