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ICD-10 Guide
ICD-10 CodesM41.42

M41.42

Billable

Neuromuscular scoliosis, cervical region

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

Code Description

ICD-10 M41.42 is a billable code used to indicate a diagnosis of neuromuscular scoliosis, cervical region.

Key Diagnostic Point:

Neuromuscular scoliosis is a type of spinal deformity characterized by an abnormal lateral curvature of the spine that occurs due to neuromuscular conditions such as cerebral palsy, muscular dystrophy, or spinal muscular atrophy. In the cervical region, this condition can lead to significant postural changes and functional impairments. The curvature may be progressive and can result in complications such as respiratory issues, pain, and reduced mobility. Neuromuscular scoliosis often requires a multidisciplinary approach for management, including physical therapy, bracing, and potentially surgical interventions such as spinal fusion. The cervical region's involvement is particularly concerning as it can affect the alignment of the head and neck, leading to further complications. Accurate diagnosis and coding are essential for appropriate treatment planning and reimbursement.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Requires understanding of neuromuscular conditions and their impact on spinal health.
  • Differentiation from other types of scoliosis (idiopathic, congenital).
  • Documentation must specify the cervical region involvement.
  • Potential for co-morbid conditions that may complicate coding.

Audit Risk Factors

  • Insufficient documentation of the neuromuscular condition.
  • Lack of clarity on the severity and progression of scoliosis.
  • Inadequate linkage between diagnosis and treatment provided.
  • Failure to document co-existing conditions.

Specialty Focus

Medical Specialties

Orthopedics

Documentation Requirements

Detailed clinical notes on spinal curvature, neurological assessments, and treatment plans.

Common Clinical Scenarios

Patients with progressive scoliosis due to muscular dystrophy requiring surgical intervention.

Billing Considerations

Ensure that the documentation reflects the neuromuscular origin of the scoliosis.

Physical Medicine and Rehabilitation

Documentation Requirements

Functional assessments, therapy progress notes, and multidisciplinary treatment plans.

Common Clinical Scenarios

Patients receiving conservative management for scoliosis with associated functional impairments.

Billing Considerations

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

Coding Guidelines

Inclusion Criteria

Use M41.42 When
  • Follow the official ICD
  • CM coding guidelines, ensuring that the diagnosis is supported by clinical documentation
  • Include details about the underlying neuromuscular condition and specify the cervical region involvement

Exclusion Criteria

Do NOT use M41.42 When
  • Exclude codes that do not pertain to neuromuscular causes

Related ICD-10 Codes

Related CPT Codes

22610CPT Code

Spinal fusion, cervical

Clinical Scenario

Used in surgical management of severe neuromuscular scoliosis.

Documentation Requirements

Operative reports detailing the procedure and indication for surgery.

Specialty Considerations

Orthopedic surgeons must document the neuromuscular condition and its impact on the surgical decision.

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 neuromuscular scoliosis, improving the accuracy of data collection and reimbursement processes. It emphasizes the need for detailed documentation of the underlying causes and the specific spinal regions affected.

ICD-9 vs ICD-10

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

Reimbursement & Billing Impact

reimbursement processes. It emphasizes the need for detailed documentation of the underlying causes and the specific spinal regions affected.

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 primary cause of neuromuscular scoliosis?

Neuromuscular scoliosis is primarily caused by conditions that affect muscle control and strength, such as cerebral palsy, muscular dystrophy, and spinal muscular atrophy.

How is neuromuscular scoliosis treated?

Treatment may include physical therapy, bracing, and surgical interventions such as spinal fusion, depending on the severity and progression of the curvature.

What documentation is needed for coding M41.42?

Documentation should include a clear diagnosis of the neuromuscular condition, details of the spinal curvature, and any treatment plans or interventions undertaken.