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ICD-10 Guide
ICD-10 CodesM41.113

M41.113

Billable

Juvenile idiopathic scoliosis, cervicothoracic region

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

Code Description

ICD-10 M41.113 is a billable code used to indicate a diagnosis of juvenile idiopathic scoliosis, cervicothoracic region.

Key Diagnostic Point:

Juvenile idiopathic scoliosis (JIS) is a form of scoliosis that occurs in children aged 10 to 18 years, characterized by a lateral curvature of the spine that is not attributable to any identifiable cause. The cervicothoracic region refers to the area of the spine that includes the cervical and upper thoracic vertebrae. This condition can lead to significant spinal deformities, affecting the patient's posture, respiratory function, and overall quality of life. The etiology of JIS remains largely unknown, but it is believed to involve a combination of genetic and environmental factors. Diagnosis typically involves clinical examination and imaging studies, such as X-rays, to assess the degree of curvature and its progression. Treatment options may include observation, bracing, or surgical intervention, particularly spinal fusion, depending on the severity of the curvature and the patient's age. Early detection and management are crucial to prevent complications associated with severe spinal deformities.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Variability in presentation and severity of scoliosis
  • Need for precise measurement of spinal curvature
  • Differentiation from other types of scoliosis
  • Documentation of treatment plans and outcomes

Audit Risk Factors

  • Inadequate documentation of curvature measurements
  • Failure to specify the idiopathic nature of the scoliosis
  • Lack of follow-up documentation on treatment efficacy
  • Misclassification of scoliosis type

Specialty Focus

Medical Specialties

Orthopedic Surgery

Documentation Requirements

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

Common Clinical Scenarios

Patients presenting with progressive scoliosis requiring surgical intervention.

Billing Considerations

Ensure accurate measurement of Cobb angle and documentation of any bracing or surgical procedures.

Pediatrics

Documentation Requirements

Growth charts, family history, and developmental assessments should be included.

Common Clinical Scenarios

Routine screenings for scoliosis in adolescents during well-child visits.

Billing Considerations

Document any referrals to specialists and follow-up care plans.

Coding Guidelines

Inclusion Criteria

Use M41.113 When
  • Follow the official ICD
  • CM coding guidelines, ensuring that the diagnosis is supported by clinical documentation
  • Include any relevant imaging studies and treatment plans

Exclusion Criteria

Do NOT use M41.113 When
  • Exclude conditions that are not idiopathic in nature

Related ICD-10 Codes

Related CPT Codes

22840CPT Code

Spinal fusion, posterior technique

Clinical Scenario

Used in cases where surgical intervention is required for severe scoliosis.

Documentation Requirements

Operative reports detailing the procedure and pre-operative assessments.

Specialty Considerations

Orthopedic surgeons must document the rationale for surgery and expected outcomes.

ICD-10 Impact

Diagnostic & Documentation Impact

Enhanced Specificity

ICD-10 Improvements

The transition to ICD-10 has allowed for more specific coding of juvenile idiopathic scoliosis, improving the accuracy of data collection and reimbursement processes. This specificity aids in better tracking of treatment outcomes and resource allocation.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of juvenile idiopathic scoliosis, improving the accuracy of data collection and reimbursement processes. This specificity aids in better tracking of treatment outcomes and resource allocation.

Reimbursement & Billing Impact

reimbursement processes. This specificity aids in better tracking of 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 juvenile idiopathic scoliosis?

Juvenile idiopathic scoliosis is a type of scoliosis that occurs in children aged 10 to 18 years, characterized by a lateral curvature of the spine without a known cause.

How is juvenile idiopathic scoliosis diagnosed?

Diagnosis is typically made through clinical examination and imaging studies, such as X-rays, which measure the degree of spinal curvature.

What are the treatment options for juvenile idiopathic scoliosis?

Treatment options include observation, bracing, and surgical intervention, such as spinal fusion, depending on the severity of the curvature.

What documentation is required for coding M41.113?

Documentation must include clinical findings, imaging results, treatment plans, and any follow-up care related to the diagnosis of juvenile idiopathic scoliosis.