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ICD-10 Guide
ICD-10 CodesM41.05

M41.05

Billable

Infantile idiopathic scoliosis, thoracolumbar region

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

Code Description

ICD-10 M41.05 is a billable code used to indicate a diagnosis of infantile idiopathic scoliosis, thoracolumbar 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 aged 0 to 3 years. The thoracolumbar region refers to the area of the spine that includes both the thoracic and lumbar vertebrae. This condition is termed 'idiopathic' because the exact cause remains unknown, although it is believed to involve a combination of genetic and environmental factors. IIS can lead to significant postural abnormalities and may affect lung function if severe. Diagnosis typically involves clinical examination and imaging studies, such as X-rays, to assess the degree of curvature. Treatment options vary based on the severity of the curvature and the age of the child, ranging from observation to bracing and, in more severe cases, surgical intervention such as spinal fusion. Early detection and management 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 measurement of spinal curvature
  • Differentiation from other types of scoliosis
  • Documentation of treatment plans and follow-up care

Audit Risk Factors

  • Inadequate documentation of curvature measurements
  • Failure to document the treatment plan and follow-up
  • Misclassification of idiopathic scoliosis as another type
  • Lack of clarity on the severity of the condition

Specialty Focus

Medical Specialties

Pediatric Orthopedics

Documentation Requirements

Detailed clinical notes on physical examination findings, imaging results, and treatment plans.

Common Clinical Scenarios

Initial diagnosis of scoliosis, monitoring progression, and planning surgical intervention.

Billing Considerations

Consideration of growth patterns and potential for curve progression in infants.

Physical Medicine and Rehabilitation

Documentation Requirements

Assessment of functional limitations and rehabilitation goals.

Common Clinical Scenarios

Rehabilitation post-surgery or bracing, and management of associated pain.

Billing Considerations

Focus on improving mobility and function while monitoring spinal alignment.

Coding Guidelines

Inclusion Criteria

Use M41.05 When
  • Follow the official ICD
  • CM coding guidelines, ensuring accurate documentation of the diagnosis, treatment, and any associated conditions
  • Include specific details about the curvature and any interventions performed

Exclusion Criteria

Do NOT use M41.05 When
No specific exclusions found.

Related ICD-10 Codes

Related CPT Codes

22800CPT Code

Spinal fusion, posterior technique

Clinical Scenario

Used in cases of severe idiopathic scoliosis requiring surgical intervention.

Documentation Requirements

Operative report detailing the procedure, indications, and postoperative care.

Specialty Considerations

Pediatric orthopedic surgeons must document growth considerations and potential complications.

ICD-10 Impact

Diagnostic & Documentation Impact

Enhanced Specificity

ICD-10 Improvements

The transition to ICD-10 has allowed for more specific coding of conditions like M41.05, improving the accuracy of data collection and reimbursement processes. This specificity helps in tracking treatment outcomes and resource allocation.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of conditions like M41.05, improving the accuracy of data collection and reimbursement processes. This specificity helps in tracking treatment outcomes and resource allocation.

Reimbursement & Billing Impact

reimbursement processes. This specificity helps in tracking treatment outcomes and resource allocation.

Resources

Clinical References

  • •
    American Academy of Orthopaedic Surgeons (AAOS)

Coding & Billing References

  • •
    American Academy of Orthopaedic Surgeons (AAOS)

Frequently Asked Questions

What is the primary treatment for M41.05?

The primary treatment for M41.05 varies based on the severity of the curvature. Mild cases may be monitored, while moderate to severe cases may require bracing or surgical intervention such as spinal fusion.