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ICD-10 Guide
ICD-10 CodesM41.4

M41.4

Billable

Neuromuscular scoliosis

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

Code Description

ICD-10 M41.4 is a billable code used to indicate a diagnosis of neuromuscular scoliosis.

Key Diagnostic Point:

Neuromuscular scoliosis is a type of scoliosis that arises from neuromuscular conditions, such as cerebral palsy, muscular dystrophy, or spinal muscular atrophy. This condition is characterized by an abnormal lateral curvature of the spine, which can lead to significant postural deformities and functional impairments. The curvature is often progressive and can worsen over time, particularly in patients with underlying neuromuscular disorders. Neuromuscular scoliosis typically presents with a combination of spinal deformities, including scoliosis, kyphosis (excessive forward bending of the spine), and lordosis (excessive inward curvature of the spine). Treatment options may include bracing, physical therapy, and surgical interventions such as spinal fusion to correct the curvature and stabilize the spine. The complexity of managing neuromuscular scoliosis lies in the multifactorial nature of the underlying conditions, necessitating a multidisciplinary approach for optimal patient outcomes.

Code Complexity Analysis

Complexity Rating: High

High Complexity

Complexity Factors

  • Variety of underlying neuromuscular conditions
  • Progressive nature of the curvature
  • Need for multidisciplinary management
  • Potential for surgical intervention

Audit Risk Factors

  • Inadequate documentation of the underlying neuromuscular condition
  • Failure to document the severity and progression of scoliosis
  • Lack of evidence for treatment decisions
  • Improper linkage between diagnosis and procedure codes

Specialty Focus

Medical Specialties

Orthopedics

Documentation Requirements

Detailed clinical notes on spinal curvature, treatment plans, and outcomes.

Common Clinical Scenarios

Patients with progressive scoliosis requiring surgical intervention.

Billing Considerations

Ensure accurate documentation of the neuromuscular condition and its impact on scoliosis.

Neurology

Documentation Requirements

Comprehensive assessment of the neuromuscular disorder and its effects on motor function.

Common Clinical Scenarios

Patients with cerebral palsy presenting with scoliosis.

Billing Considerations

Document neurological assessments and any related therapies.

Coding Guidelines

Inclusion Criteria

Use M41.4 When
  • Follow official ICD
  • 10 coding guidelines, ensuring accurate documentation of the underlying neuromuscular condition
  • Include details on the severity of scoliosis and any associated complications

Exclusion Criteria

Do NOT use M41.4 When
  • Exclude codes for idiopathic scoliosis unless specified

Related ICD-10 Codes

Related CPT Codes

22612CPT Code

Spinal fusion, posterior technique

Clinical Scenario

Used for surgical correction of severe neuromuscular scoliosis.

Documentation Requirements

Pre-operative imaging, surgical notes, and post-operative follow-up.

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 neuromuscular scoliosis, improving the accuracy of data collection and reimbursement processes. It emphasizes the need for detailed documentation of underlying conditions.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of neuromuscular scoliosis, improving the accuracy of data collection and reimbursement processes. It emphasizes the need for detailed documentation of underlying conditions.

Reimbursement & Billing Impact

reimbursement processes. It emphasizes the need for detailed documentation of underlying conditions.

Resources

Clinical References

  • •
    American Academy of Orthopaedic Surgeons

Coding & Billing References

  • •
    American Academy of Orthopaedic Surgeons

Frequently Asked Questions

What is the primary cause of neuromuscular scoliosis?

Neuromuscular scoliosis is primarily caused by underlying neuromuscular disorders that lead to muscle imbalances affecting spinal alignment.