Other secondary scoliosis, thoracolumbar region
ICD-10 M41.55 is a billable code used to indicate a diagnosis of other secondary scoliosis, thoracolumbar region.
M41.55 refers to a specific type of scoliosis that occurs in the thoracolumbar region of the spine, which is the area encompassing the lower thoracic and upper lumbar vertebrae. This condition is classified as secondary scoliosis, meaning it arises as a result of another underlying condition or factor, such as neuromuscular disorders, congenital anomalies, or previous spinal injuries. Patients with M41.55 may present with a variety of symptoms, including uneven shoulders, a prominent rib cage, or back pain. The thoracolumbar region is particularly significant as it bears much of the body's weight and is crucial for mobility. Treatment options may include physical therapy, bracing, or surgical interventions such as spinal fusion, depending on the severity and underlying cause of the scoliosis. Accurate diagnosis and coding are essential for effective treatment planning and reimbursement.
Detailed clinical notes, imaging studies, and treatment plans must be documented to support the diagnosis and any surgical interventions.
Patients presenting with progressive scoliosis due to neuromuscular disorders or post-surgical changes.
Ensure that the documentation clearly states the type of scoliosis and any associated conditions.
Functional assessments, treatment plans, and progress notes are essential for justifying therapy and interventions.
Patients requiring rehabilitation post-surgery or those with scoliosis impacting mobility.
Document the impact of scoliosis on daily activities and the effectiveness of rehabilitation efforts.
Used in surgical correction of severe scoliosis cases.
Operative reports detailing the procedure and indications for surgery.
Orthopedic surgeons must document the rationale for surgical intervention.
Primary scoliosis occurs without an identifiable cause, while secondary scoliosis is due to an underlying condition, such as a neuromuscular disorder or trauma.
