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ICD-10 Guide
ICD-10 CodesM41.02

M41.02

Billable

Infantile idiopathic scoliosis, cervical region

BILLABLE STATUSYes
IMPLEMENTATION DATEOctober 1, 2015
LAST UPDATED09/17/2025

Code Description

ICD-10 M41.02 is a billable code used to indicate a diagnosis of infantile idiopathic scoliosis, cervical region.

Key Diagnostic Point:

Infantile idiopathic scoliosis (IIS) is a spinal deformity characterized by an abnormal lateral curvature of the spine that occurs in children under the age of 3. The condition is termed 'idiopathic' because the exact cause remains unknown, although it is believed to involve a combination of genetic and environmental factors. In the cervical region, this curvature can lead to significant postural abnormalities and potential complications, including respiratory issues and discomfort. The diagnosis is typically made through clinical examination and imaging studies, such as X-rays, which reveal the degree of curvature. Treatment options vary based on the severity of the curvature and the age of the child, ranging from observation and physical therapy to bracing and, in severe cases, surgical intervention. Surgical options may include spinal fusion procedures to correct the curvature and stabilize the spine. Early diagnosis and intervention are crucial to prevent progression and associated complications.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Variability in presentation and severity of scoliosis in infants
  • Need for precise imaging documentation
  • Differentiation from other types of scoliosis
  • Potential for co-existing conditions affecting treatment

Audit Risk Factors

  • Inadequate documentation of curvature measurements
  • Failure to document the treatment plan and follow-up
  • Misclassification of idiopathic vs. secondary scoliosis
  • Lack of imaging studies to support diagnosis

Specialty Focus

Medical Specialties

Pediatric Orthopedics

Documentation Requirements

Detailed clinical notes, imaging results, and treatment plans must be documented.

Common Clinical Scenarios

Diagnosis of scoliosis during routine check-ups, treatment planning for bracing or surgery.

Billing Considerations

Consideration of growth patterns and potential for progression is crucial.

Physical Therapy

Documentation Requirements

Progress notes detailing therapy sessions, patient response, and modifications to treatment.

Common Clinical Scenarios

Rehabilitation following spinal surgery or bracing.

Billing Considerations

Therapists must document functional improvements and any changes in curvature.

Coding Guidelines

Inclusion Criteria

Use M41.02 When
  • Follow ICD
  • CM guidelines for coding spinal deformities, ensuring accurate documentation of curvature and treatment
  • Include any relevant co
  • morbidities and specify the location of the curvature

Exclusion Criteria

Do NOT use M41.02 When
No specific exclusions found.

Related ICD-10 Codes

Related CPT Codes

22558CPT Code

Spinal fusion, cervical

Clinical Scenario

Used in cases of severe curvature requiring surgical correction.

Documentation Requirements

Pre-operative assessment, imaging studies, and surgical notes.

Specialty Considerations

Pediatric orthopedic surgeons must document growth considerations.

ICD-10 Impact

Diagnostic & Documentation Impact

Enhanced Specificity

ICD-10 Improvements

The transition to ICD-10 has allowed for more specific coding of scoliosis types, improving data accuracy and treatment tracking. M41.02 provides a clear distinction for idiopathic cases in infants, which aids in research and treatment planning.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of scoliosis types, improving data accuracy and treatment tracking. M41.02 provides a clear distinction for idiopathic cases in infants, which aids in research and treatment planning.

Reimbursement & Billing Impact

The transition to ICD-10 has allowed for more specific coding of scoliosis types, improving data accuracy and treatment tracking. M41.02 provides a clear distinction for idiopathic cases in infants, which aids in research and treatment planning.

Resources

Clinical References

  • •
    American Academy of Orthopaedic Surgeons

Coding & Billing References

  • •
    American Academy of Orthopaedic Surgeons

Frequently Asked Questions

What is the primary treatment for M41.02?

The primary treatment for infantile idiopathic scoliosis may include observation, bracing, or surgical intervention, depending on the severity of the curvature and the age of the child.