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ICD-10 Guide
ICD-10 CodesM41.25

M41.25

Billable

Other idiopathic scoliosis, thoracolumbar region

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

Code Description

ICD-10 M41.25 is a billable code used to indicate a diagnosis of other idiopathic scoliosis, thoracolumbar region.

Key Diagnostic Point:

M41.25 refers to a specific type of idiopathic scoliosis affecting the thoracolumbar region of the spine. Idiopathic scoliosis is characterized by an abnormal lateral curvature of the spine that typically develops during adolescence. The thoracolumbar region encompasses the lower thoracic and upper lumbar vertebrae, which can lead to significant postural changes and potential complications if left untreated. Patients may present with asymmetry in shoulder height, rib prominence, and waistline irregularities. The etiology of idiopathic scoliosis remains largely unknown, although genetic factors and environmental influences are believed to play a role. Diagnosis is primarily made through physical examination and imaging studies, such as X-rays, which assess the degree of curvature. Treatment options vary based on the severity of the curvature and the age of the patient, ranging from observation and bracing to surgical interventions like spinal fusion. Surgical procedures aim to correct the curvature and stabilize the spine, thereby improving function and reducing pain.

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 deformities

Audit Risk Factors

  • Inadequate documentation of curvature measurements
  • Failure to specify the type of scoliosis
  • Lack of follow-up documentation post-treatment
  • Misclassification of idiopathic scoliosis as congenital

Specialty Focus

Medical Specialties

Orthopedic Surgery

Documentation Requirements

Detailed imaging reports, surgical notes, and follow-up assessments.

Common Clinical Scenarios

Surgical correction of scoliosis, monitoring of progression in adolescents.

Billing Considerations

Ensure accurate measurement of Cobb angle and documentation of any associated spinal deformities.

Physical Medicine and Rehabilitation

Documentation Requirements

Comprehensive assessments of functional limitations and treatment plans.

Common Clinical Scenarios

Conservative management of scoliosis, physical therapy interventions.

Billing Considerations

Documenting the impact of scoliosis on daily activities and quality of life.

Coding Guidelines

Inclusion Criteria

Use M41.25 When
  • According to ICD
  • 10 coding guidelines, M41
  • 25 should be used when idiopathic scoliosis is confirmed in the thoracolumbar region
  • Coders must ensure that the diagnosis is supported by clinical documentation and imaging studies

Exclusion Criteria

Do NOT use M41.25 When
  • Exclusion criteria include scoliosis due to known causes such as congenital anomalies or neuromuscular conditions

Related ICD-10 Codes

Related CPT Codes

22612CPT Code

Spinal fusion, posterior technique

Clinical Scenario

Used in surgical correction of idiopathic scoliosis.

Documentation Requirements

Operative report detailing the procedure and indication.

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 scoliosis types, improving the accuracy of data collection and reimbursement processes. M41.25 provides a clear distinction for idiopathic scoliosis in the thoracolumbar region, facilitating better patient management and research.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of scoliosis types, improving the accuracy of data collection and reimbursement processes. M41.25 provides a clear distinction for idiopathic scoliosis in the thoracolumbar region, facilitating better patient management and research.

Reimbursement & Billing Impact

reimbursement processes. M41.25 provides a clear distinction for idiopathic scoliosis in the thoracolumbar region, facilitating better patient management and research.

Resources

Clinical References

  • •
    American Academy of Orthopaedic Surgeons (AAOS)

Coding & Billing References

  • •
    American Academy of Orthopaedic Surgeons (AAOS)

Frequently Asked Questions

What is the significance of the Cobb angle in scoliosis?

The Cobb angle is a measurement used to quantify the degree of spinal curvature in scoliosis. It is critical for diagnosing the severity of the condition and determining the appropriate treatment plan.