Spinal enthesopathy
ICD-10 M46.0 is a billable code used to indicate a diagnosis of spinal enthesopathy.
Spinal enthesopathy refers to a condition characterized by inflammation and degeneration of the entheses, the sites where tendons and ligaments attach to the spine. This condition is often associated with various spondylopathies, including ankylosing spondylitis, which is a type of inflammatory arthritis that primarily affects the spine and can lead to severe, chronic pain and discomfort. Spinal enthesopathy can also be linked to spinal stenosis, a narrowing of the spinal canal that can compress the spinal cord and nerves, leading to pain, numbness, and weakness. Inflammatory spine conditions, such as psoriatic arthritis and reactive arthritis, may also present with enthesopathy, complicating the clinical picture. Diagnosis typically involves a combination of clinical evaluation, imaging studies, and laboratory tests to assess inflammation and rule out other conditions. Treatment may include anti-inflammatory medications, physical therapy, and in some cases, surgical intervention. Accurate coding is essential for proper reimbursement and to reflect the complexity of the patient's condition.
Detailed history of symptoms, physical examination findings, and imaging results.
Patients presenting with chronic back pain, stiffness, and reduced mobility.
Documentation must clearly differentiate between enthesopathy and other forms of spondylopathy.
Surgical notes, imaging studies, and pre-operative evaluations.
Patients requiring surgical intervention for spinal stenosis or severe enthesopathy.
Accurate coding of co-existing conditions is crucial for surgical cases.
Used when injecting corticosteroids into the spine for enthesopathy treatment.
Document the indication for injection and the specific site.
Rheumatologists often perform these procedures in an outpatient setting.
Spinal enthesopathy is primarily caused by inflammatory conditions such as ankylosing spondylitis, psoriatic arthritis, and other spondylopathies that lead to inflammation at the entheses.
