Spinal enthesopathy, cervical region
ICD-10 M46.02 is a billable code used to indicate a diagnosis of spinal enthesopathy, cervical region.
Spinal enthesopathy in the cervical region refers to a condition characterized by inflammation and degeneration at the sites where tendons and ligaments attach to the cervical vertebrae. This condition can lead to pain, stiffness, and reduced mobility in the neck. It is often associated with various inflammatory spine conditions, including ankylosing spondylitis, which is a type of spondyloarthritis that primarily affects the spine and the sacroiliac joints. Patients may experience chronic pain and progressive stiffness, particularly in the morning or after periods of inactivity. The cervical region is particularly vulnerable due to its range of motion and the stress placed on the cervical spine during daily activities. Diagnosis typically involves a combination of clinical evaluation, imaging studies, and sometimes laboratory tests to rule out other conditions. Treatment may include physical therapy, anti-inflammatory medications, and in some cases, surgical intervention. Understanding the nuances of spinal enthesopathy is crucial for accurate coding and effective patient management.
Detailed history of symptoms, physical examination findings, and imaging results.
Patients presenting with chronic neck pain, stiffness, and a history of inflammatory arthritis.
Documentation must clearly outline the inflammatory nature of the condition and any associated systemic symptoms.
Surgical notes, pre-operative assessments, and post-operative follow-ups.
Patients requiring surgical intervention for severe enthesopathy-related symptoms.
Clear documentation of conservative treatment attempts prior to surgery is essential.
Used when performing injections for pain relief in cases of cervical enthesopathy.
Document the indication for the procedure, the joint involved, and the patient's response.
Rheumatologists may perform this procedure as part of a comprehensive treatment plan.
Spinal enthesopathy refers to inflammation and degeneration at the sites where tendons and ligaments attach to the spine, leading to pain and functional impairment.
M46.02 specifically denotes enthesopathy in the cervical region, while other codes may refer to different types of spinal conditions or locations.
