Scoliosis, unspecified
ICD-10 M41.9 is a billable code used to indicate a diagnosis of scoliosis, unspecified.
Scoliosis is a three-dimensional deformity of the spine characterized by lateral curvature and rotation of the vertebrae. It can occur in various forms, including idiopathic, congenital, and neuromuscular scoliosis. The condition may present at any age, but it is most commonly diagnosed in adolescents. The curvature can lead to asymmetry in the shoulders, waist, and hips, and may cause discomfort or pain. In severe cases, scoliosis can affect lung function and overall health. Diagnosis typically involves physical examination and imaging studies such as X-rays, which help determine 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. The unspecified nature of this code indicates that the specific type or cause of scoliosis has not been documented, which can complicate treatment planning and management.
Detailed notes on curvature measurements, treatment plans, and follow-up assessments.
Surgical intervention for severe scoliosis, monitoring of adolescent patients with idiopathic scoliosis.
Ensure that the type of scoliosis is documented if known, as this affects treatment and coding.
Progress notes detailing functional assessments and treatment responses.
Rehabilitation post-surgery or management of scoliosis through physical therapy.
Documenting the impact of scoliosis on mobility and function is crucial for accurate coding.
Used for surgical correction of severe scoliosis.
Operative report detailing the procedure and indication for surgery.
Orthopedic surgeons must document the specific type of scoliosis if known.
To avoid using M41.9, ensure that the specific type of scoliosis is documented, including any curvature measurements and the underlying cause if known.
