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ICD-10 Guide
ICD-10 CodesM41.08

M41.08

Billable

Infantile idiopathic scoliosis, sacral and sacrococcygeal region

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

Code Description

ICD-10 M41.08 is a billable code used to indicate a diagnosis of infantile idiopathic scoliosis, sacral and sacrococcygeal region.

Key Diagnostic Point:

Infantile idiopathic scoliosis is a spinal deformity characterized by an abnormal lateral curvature of the spine that occurs in children under the age of three. This condition is classified as 'idiopathic' because the exact cause remains unknown, although it is believed to involve a combination of genetic and environmental factors. The sacral and sacrococcygeal region refers to the lower part of the spine, which includes the sacrum and coccyx. In infants, this condition can lead to significant postural abnormalities and may affect growth and development. Early diagnosis is crucial, as untreated scoliosis can progress and lead to complications such as respiratory issues and chronic pain. Treatment options may include observation, bracing, or surgical intervention, particularly spinal fusion, depending on the severity and progression of the curvature. Regular monitoring and multidisciplinary management are essential for optimal outcomes.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Variability in presentation and progression of scoliosis in infants
  • Need for precise documentation of curvature measurements
  • Differentiation from other types of scoliosis and spinal deformities
  • Potential for co-existing conditions affecting treatment

Audit Risk Factors

  • Inadequate documentation of curvature measurements
  • Failure to document the idiopathic nature of the condition
  • Lack of follow-up notes on treatment effectiveness
  • Incorrect coding of associated conditions

Specialty Focus

Medical Specialties

Pediatric Orthopedics

Documentation Requirements

Detailed clinical notes on curvature measurements, treatment plans, and follow-up assessments.

Common Clinical Scenarios

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

Billing Considerations

Documentation must clearly indicate the idiopathic nature and any associated conditions.

Physical Therapy

Documentation Requirements

Progress notes detailing treatment interventions, patient response, and functional outcomes.

Common Clinical Scenarios

Rehabilitation post-surgery or bracing, and ongoing management of scoliosis.

Billing Considerations

Therapists should document specific exercises and their impact on spinal alignment.

Coding Guidelines

Inclusion Criteria

Use M41.08 When
  • Follow official ICD
  • 10 coding guidelines, ensuring accurate documentation of the idiopathic nature of the condition
  • Include curvature measurements and treatment plans

Exclusion Criteria

Do NOT use M41.08 When
  • Exclude conditions that are not idiopathic or do not pertain to the sacral and sacrococcygeal region

Related ICD-10 Codes

Related CPT Codes

22612CPT Code

Spinal fusion, posterior technique

Clinical Scenario

Used for surgical correction of severe idiopathic scoliosis.

Documentation Requirements

Operative report detailing the procedure, indications, and post-operative care.

Specialty Considerations

Orthopedic surgeons must document the rationale for surgical intervention.

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 M41.08, improving the accuracy of data collection and reimbursement processes. It emphasizes the need for detailed documentation to support the diagnosis.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of conditions like M41.08, improving the accuracy of data collection and reimbursement processes. It emphasizes the need for detailed documentation to support the diagnosis.

Reimbursement & Billing Impact

reimbursement processes. It emphasizes the need for detailed documentation to support the diagnosis.

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 M41.08?

The primary treatment for M41.08 may include observation, bracing, or surgical intervention, depending on the severity of the curvature and the child's age.