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ICD-10 Guide
ICD-10 CodesM41.54

M41.54

Billable

Other secondary scoliosis, thoracic region

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

Code Description

ICD-10 M41.54 is a billable code used to indicate a diagnosis of other secondary scoliosis, thoracic region.

Key Diagnostic Point:

M41.54 refers to other secondary scoliosis localized in the thoracic region, which is a spinal deformity characterized by an abnormal lateral curvature of the spine. This condition can arise from various underlying causes, including neuromuscular disorders, congenital anomalies, or as a result of trauma. Secondary scoliosis is differentiated from idiopathic scoliosis, which has no identifiable cause. Patients may present with symptoms such as back pain, postural abnormalities, and in severe cases, respiratory issues due to compromised thoracic cavity space. Diagnosis typically involves physical examination and imaging studies, such as X-rays, to assess the curvature's degree and pattern. Treatment options may vary based on the severity and underlying cause, ranging from physical therapy and bracing to surgical interventions like spinal fusion, which aims to stabilize the spine and prevent further curvature progression. Understanding the nuances of secondary scoliosis is crucial for accurate coding and effective patient management.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Differentiation from idiopathic scoliosis
  • Need for detailed documentation of underlying causes
  • Variability in treatment approaches based on etiology
  • Potential for co-existing spinal deformities

Audit Risk Factors

  • Inadequate documentation of the underlying cause
  • Failure to specify the thoracic region
  • Incorrect coding of co-existing conditions
  • Lack of clarity in treatment plans

Specialty Focus

Medical Specialties

Orthopedic Surgery

Documentation Requirements

Detailed surgical notes, imaging results, and pre-operative assessments are essential.

Common Clinical Scenarios

Patients undergoing spinal fusion for secondary scoliosis due to neuromuscular disorders.

Billing Considerations

Ensure that the surgical approach and any complications are well-documented.

Physical Medicine and Rehabilitation

Documentation Requirements

Comprehensive evaluations, treatment plans, and progress notes are necessary.

Common Clinical Scenarios

Patients receiving conservative management for scoliosis with physical therapy.

Billing Considerations

Documenting functional limitations and response to therapy is critical.

Coding Guidelines

Inclusion Criteria

Use M41.54 When
  • According to ICD
  • 10 coding guidelines, M41
  • 54 should be used when the scoliosis is secondary to another condition
  • Coders must ensure that the underlying cause is documented and that the thoracic region is specified

Exclusion Criteria

Do NOT use M41.54 When
  • Exclusion criteria include idiopathic scoliosis and other specific types of scoliosis not classified under this code

Related ICD-10 Codes

Related CPT Codes

22612CPT Code

Spinal fusion, posterior technique

Clinical Scenario

Used in surgical treatment of severe secondary scoliosis.

Documentation Requirements

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

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. M41.54 provides a clear distinction for secondary scoliosis, which aids in clinical 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. M41.54 provides a clear distinction for secondary scoliosis, which aids in clinical management and research.

Reimbursement & Billing Impact

reimbursement processes. M41.54 provides a clear distinction for secondary scoliosis, which aids in clinical management and research.

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 primary and secondary scoliosis?

Primary scoliosis, often idiopathic, has no identifiable cause, while secondary scoliosis arises from underlying conditions such as neuromuscular disorders or trauma.