ICD-10-CM · Spine

M48.37

Traumatic spondylopathy of the lumbosacral region — structural vertebral pathology at the L5–S1 junction resulting from prior trauma rather than degenerative or inflammatory disease.

Verified May 8, 2026 · 7 sources ↓

Status: Billable
Chapter: 13
Related CPT: 15
Region: Spine

Drawn from CDCICD10DataCMSAAPCAAOS

Documentation tips

What should appear in the chart to support M48.37.

Source · Editorial brief grounded in 7 cited references ↓

Specify the lumbosacral region (L5–S1 junction) by name in the clinical note — 'lumbosacral' must appear in documentation to justify M48.37 over M48.36 (lumbar) or M48.30 (unspecified).
Document the inciting traumatic event: date, mechanism (e.g., fall, MVA, compression injury), and how it caused the current structural vertebral change.
Include imaging findings that confirm structural pathology at the lumbosacral level — MRI, CT, or plain film evidence of vertebral body changes, endplate irregularity, or ligamentous injury sequelae.
If an acute fracture or dislocation S-code was previously assigned, note its resolution and the transition to chronic post-traumatic spondylopathy to justify the switch to M48.37.
Record functional deficits and prior conservative care history when billing for rehabilitative services or spinal procedures, as CMS coverage policies tie reimbursement to documented clinical necessity.

Related CPT procedures

Procedure codes commonly billed with M48.37. Linking the right diagnosis to the right procedure is what establishes medical necessity.

Source · CMS LCDs · AAOS specialty guidance · claims-pattern analysis

97110 $29.06

Therapeutic exercise billed per 15-minute unit, targeting strength, endurance, range of motion, or flexibility with direct one-on-one patient contact.

72100 $40.42

Radiologic examination of the lumbosacral spine capturing two or three views, used to evaluate the lumbar vertebrae and sacrum for injury, degeneration, or structural abnormality.

72110 $53.44

Radiologic examination of the lumbar spine (lumbosacral) with a minimum of four views, including oblique and/or bending views.

72114 $61.79

Radiologic examination of the lumbosacral spine, complete series with bending (flexion/extension) views — minimum of 6 views total.

72120 $42.09

Radiologic examination of the lumbosacral spine using bending views only, minimum of four views, to assess spinal flexibility and alignment.

63030 $898.15

Single-interspace lumbar laminotomy with nerve root decompression, including partial facetectomy, foraminotomy, and/or herniated disc excision performed via open surgical technique.

63047 $1,065.49

Lumbar laminectomy at a single vertebral segment that also includes facetectomy and foraminotomy for decompression of the spinal cord, cauda equina, and/or nerve roots — unilateral or bilateral.

22612 $1,467.64

Posterior or posterolateral lumbar arthrodesis of a single interspace, performed via a posterior approach with bone graft and typically pedicle screw fixation to achieve vertebral segment fusion.

22630 $1,510.72

Posterior interbody arthrodesis of a single lumbar interspace, including laminectomy and/or discectomy performed to prepare the interspace for fusion rather than for decompression.

22633 $1,700.11

Single-level lumbar arthrodesis combining posterior or posterolateral technique with posterior interbody technique, including laminectomy and/or discectomy sufficient to prepare the interspace — performed as one surgical session at one lumbar interspace.

97530 View procedure details

97535 View procedure details

72132 View procedure details

64635 View procedure details

64636 View procedure details

Common coding pitfalls

The recurring mistakes coders make with M48.37 and adjacent codes.

Source · Editorial brief grounded in CDC ICD-10-CM tabular guidance, AAOS coding references, and cited references ↓

Assigning M48.37 during the active acute injury encounter — use the appropriate S-code (e.g., S33.x series for lumbosacral dislocations/sprains) for the acute phase; M48.37 applies to the chronic post-traumatic condition.
Defaulting to M48.30 (site unspecified) when the lumbosacral region is clearly documented — specificity is required and auditable.
Confusing M48.36 (lumbar region, L1–L5) with M48.37 (lumbosacral region, L5–S1) — the distinction depends on which spinal segment the pathology is centered at, as documented by imaging or the treating clinician.
Appending a 7th-character extension to M48.37 — unlike M48.4x fatigue fracture codes, M48.37 does not take a 7th character; adding one creates an invalid code.
Using M48.37 without an external cause code when payer policy or clinical context calls for documenting the mechanism of the original trauma — consider a Z87 (personal history) or external cause code to complete the record.

Clinical context

Source · Editorial summary grounded in 7 cited references ↓

M48.37 captures post-traumatic vertebral changes specifically at the lumbosacral junction (the articulation between the fifth lumbar vertebra and the sacrum). Use it when the clinical record establishes a traumatic origin — fracture, dislocation, or significant mechanical injury — and the current encounter addresses the resulting spondylopathy, not the acute injury itself. If the patient is still in active treatment for an acute spinal fracture or dislocation, lead with the appropriate S-code; M48.37 belongs once the injury has resolved into a chronic structural or functional deficit.

Within the M48.3 family, the 7th character does not apply — M48.37 is a complete billable code with no extension needed. Distinguish it from adjacent codes: M48.36 covers the lumbar region (L1–L5), M48.38 covers the sacral and sacrococcygeal region, and M48.30 is the fallback when documentation fails to specify a spinal region. Never use M48.30 if the lumbosacral region is documented.

This code is recognized as supporting medical necessity for outpatient occupational therapy, spinal cord stimulator procedures, and other rehabilitative and interventional services per CMS billing and coding articles. When chronic lumbosacral pain follows a documented traumatic event and conservative care has been exhausted, M48.37 paired with the appropriate procedure code creates a defensible claim record.

Sibling codes

Other billable codes under M48.3 (laterality / anatomic variants).

M48.34

Traumatic spondylopathy, thoracic region

M48.38

Traumatic spondylopathy, sacral and sacrococcygeal region

M48.35

Traumatic spondylopathy, thoracolumbar region

M48.32

Traumatic spondylopathy, cervical region

M48.31

Traumatic spondylopathy, occipito-atlanto-axial region

M48.33

Traumatic spondylopathy, cervicothoracic region

M48.36

Traumatic spondylopathy, lumbar region

M48.30

Traumatic spondylopathy, site unspecified

Frequently asked questions

Source · Generated from the editorial pipeline, verified against 7 cited references ↓

01Does M48.37 require a 7th-character extension?

No. M48.37 is a complete billable code. The 7th-character extensions (A/D/S for initial/subsequent/sequela encounters) apply to the M48.4x fatigue fracture and M48.5x collapsed vertebra subcategories, not to M48.3x traumatic spondylopathy codes.

02When should I use M48.37 instead of an acute S-code?

Use an S-code (e.g., S33 series) for the active acute injury phase. Switch to M48.37 once the acute injury has resolved and the encounter addresses residual or chronic post-traumatic vertebral changes at the lumbosacral level.

03What distinguishes M48.37 from M48.36?

M48.36 covers traumatic spondylopathy of the lumbar region (L1–L5); M48.37 is specific to the lumbosacral region (the L5–S1 junction). The treating clinician or imaging report must identify which segment is affected.

04Can M48.37 support medical necessity for a spinal cord stimulator?

Yes. CMS Billing and Coding Article A57792 lists M48.37 as an ICD-10-CM code that supports medical necessity for spinal cord stimulator procedures for chronic pain.

05Is M48.37 appropriate for outpatient physical or occupational therapy billing?

Yes. CMS Billing and Coding Article A53064 (Outpatient Occupational Therapy) includes M48.37 as a supporting diagnosis. Ensure documentation reflects functional deficits that justify skilled therapeutic intervention.

06Should I code the original trauma separately alongside M48.37?

When payer guidelines or clinical context require it, add a personal history code (e.g., Z87.39) or an external cause code to document the mechanism of the original injury. M48.37 alone does not convey the cause; supplemental coding strengthens the audit trail.

07What imaging is most useful to support M48.37?

MRI or CT of the lumbosacral spine demonstrating post-traumatic vertebral body changes, endplate irregularity, or ligamentous sequelae at L5–S1 is most defensible. Plain film evidence of chronic bony remodeling or alignment changes also supports the diagnosis.

Sources & references

Editorial content was developed using the following public sources. Last verified May 8, 2026.

Mira AI Scribe

Mira captures the documented traumatic origin (mechanism, date of injury), confirmation that the lumbosacral region (L5–S1) is affected, relevant imaging findings, and the transition from acute injury to chronic structural spondylopathy. That prevents fallback to unspecified M48.30, misassignment to lumbar M48.36, and claim denials tied to missing medical-necessity documentation for rehabilitation or interventional procedures.

See how Mira captures M48.37 documentation