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ICD-10 Guide
ICD-10 CodesM41.22

M41.22

Billable

Other idiopathic scoliosis, cervical region

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

Code Description

ICD-10 M41.22 is a billable code used to indicate a diagnosis of other idiopathic scoliosis, cervical region.

Key Diagnostic Point:

M41.22 refers to a specific type of idiopathic scoliosis that occurs in the cervical region of the spine. Idiopathic scoliosis is characterized by an abnormal lateral curvature of the spine that is not attributable to any identifiable cause. In the cervical region, this condition can lead to various complications, including neck pain, reduced range of motion, and potential neurological deficits if the curvature compresses spinal nerves. The etiology of idiopathic scoliosis remains largely unknown, but it is believed to involve genetic, environmental, and biomechanical factors. Diagnosis typically involves physical examination and imaging studies, such as X-rays, to assess the degree of curvature and its impact on spinal alignment. Treatment options may vary based on the severity of the curvature and the patient's age, ranging from observation and physical therapy to surgical interventions like spinal fusion. Spinal fusion aims to stabilize the spine by fusing adjacent vertebrae, thereby reducing pain and preventing further curvature progression. Understanding the nuances of M41.22 is crucial for accurate coding and appropriate management of patients with this condition.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Variability in presentation and severity of scoliosis
  • Need for precise documentation of curvature measurements
  • Differentiation from other types of scoliosis
  • Potential for co-existing spinal conditions

Audit Risk Factors

  • Inadequate documentation of curvature measurements
  • Failure to specify the region of the spine affected
  • Misclassification of idiopathic scoliosis as congenital or neuromuscular
  • Lack of supporting evidence for surgical interventions

Specialty Focus

Medical Specialties

Orthopedic Surgery

Documentation Requirements

Detailed imaging reports, surgical notes, and follow-up assessments are necessary to support the diagnosis and treatment plan.

Common Clinical Scenarios

Patients presenting with neck pain and abnormal spinal curvature, requiring surgical intervention.

Billing Considerations

Ensure accurate measurement of Cobb angles and documentation of any neurological assessments.

Physical Medicine and Rehabilitation

Documentation Requirements

Comprehensive evaluations including functional assessments and treatment plans focusing on physical therapy.

Common Clinical Scenarios

Patients undergoing conservative management for idiopathic scoliosis with physical therapy.

Billing Considerations

Document the patient's response to therapy and any changes in symptoms or function.

Coding Guidelines

Inclusion Criteria

Use M41.22 When
  • According to ICD
  • 10 coding guidelines, M41
  • 22 should be used when the scoliosis is idiopathic and specifically affects the cervical region
  • Coders must ensure that the diagnosis is supported by clinical documentation and imaging studies

Exclusion Criteria

Do NOT use M41.22 When
  • Exclusion criteria include scoliosis due to known causes such as congenital anomalies or neuromuscular disorders

Related ICD-10 Codes

Related CPT Codes

22612CPT Code

Spinal fusion, cervical

Clinical Scenario

Used in surgical treatment of severe idiopathic scoliosis affecting the cervical region.

Documentation Requirements

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

Specialty Considerations

Orthopedic surgeons must document the rationale for surgical intervention 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 scoliosis types, improving the accuracy of diagnoses and treatment tracking. M41.22 provides a clear distinction for idiopathic scoliosis in the cervical region, enhancing clinical understanding and management.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of scoliosis types, improving the accuracy of diagnoses and treatment tracking. M41.22 provides a clear distinction for idiopathic scoliosis in the cervical region, enhancing clinical understanding and management.

Reimbursement & Billing Impact

reimbursement and compliance with payer requirements.

Resources

Clinical References

  • •
    ICD-10-CM Official Guidelines for Coding and Reporting

Coding & Billing References

  • •
    ICD-10-CM Official Guidelines for Coding and Reporting

Frequently Asked Questions

What is the difference between idiopathic scoliosis and congenital scoliosis?

Idiopathic scoliosis has no known cause and typically develops during adolescence, while congenital scoliosis is due to structural anomalies present at birth.