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ICD-10 Guide
ICD-10 CodesM46.30

M46.30

Billable

Infection of intervertebral disc (pyogenic), site unspecified

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

Code Description

ICD-10 M46.30 is a billable code used to indicate a diagnosis of infection of intervertebral disc (pyogenic), site unspecified.

Key Diagnostic Point:

Infection of the intervertebral disc, specifically pyogenic in nature, refers to a bacterial infection that affects the disc space between vertebrae. This condition can lead to severe back pain, fever, and neurological deficits due to inflammation and potential compression of surrounding structures. Pyogenic discitis is often associated with hematogenous spread from distant infections or direct extension from adjacent osteomyelitis. The clinical presentation may include localized tenderness, limited range of motion, and systemic signs of infection. Diagnosis typically involves imaging studies such as MRI or CT scans, which can reveal disc space narrowing, endplate erosion, and paravertebral soft tissue abscesses. Treatment usually involves a combination of antibiotics and, in some cases, surgical intervention to drain abscesses or debride infected tissue. The unspecified site indicates that the exact location of the infection is not documented, which can complicate treatment and management.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Unspecified site can lead to ambiguity in treatment plans.
  • Differentiating from other spinal infections like osteomyelitis.
  • Requires thorough documentation of clinical findings.
  • Potential overlap with other spondylopathies and inflammatory conditions.

Audit Risk Factors

  • Inadequate documentation of clinical findings.
  • Failure to specify the site of infection.
  • Lack of imaging studies to support diagnosis.
  • Inconsistent coding with treatment provided.

Specialty Focus

Medical Specialties

Orthopedic Surgery

Documentation Requirements

Detailed operative notes, imaging results, and pre-operative assessments.

Common Clinical Scenarios

Surgical intervention for abscess drainage or debridement of infected disc tissue.

Billing Considerations

Ensure clear documentation of the surgical site and findings to support coding.

Infectious Disease

Documentation Requirements

Comprehensive history of infection, laboratory results, and treatment plans.

Common Clinical Scenarios

Management of pyogenic infections with antibiotic therapy and monitoring for complications.

Billing Considerations

Documenting the source of infection and response to treatment is crucial for accurate coding.

Coding Guidelines

Inclusion Criteria

Use M46.30 When
  • According to ICD
  • 10 coding guidelines, M46
  • 30 should be used when there is a confirmed diagnosis of pyogenic infection of the intervertebral disc without a specified site
  • Coders must ensure that documentation supports the diagnosis and that all relevant clinical findings are included

Exclusion Criteria

Do NOT use M46.30 When
No specific exclusions found.

Related ICD-10 Codes

Related CPT Codes

63030CPT Code

Laminectomy, facetectomy, and/or foraminotomy

Clinical Scenario

Used when surgical intervention is required for disc infection management.

Documentation Requirements

Operative report detailing the procedure and indication for surgery.

Specialty Considerations

Orthopedic surgeons must document the rationale for surgical intervention clearly.

ICD-10 Impact

Diagnostic & Documentation Impact

Enhanced Specificity

ICD-10 Improvements

The transition to ICD-10 has allowed for more specific coding of conditions like pyogenic discitis, improving the accuracy of diagnosis and treatment tracking. M46.30 provides a clear code for infections that may have previously been coded more generally, enhancing data collection and analysis.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of conditions like pyogenic discitis, improving the accuracy of diagnosis and treatment tracking. M46.30 provides a clear code for infections that may have previously been coded more generally, enhancing data collection and analysis.

Reimbursement & Billing Impact

The transition to ICD-10 has allowed for more specific coding of conditions like pyogenic discitis, improving the accuracy of diagnosis and treatment tracking. M46.30 provides a clear code for infections that may have previously been coded more generally, enhancing data collection and analysis.

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 primary cause of pyogenic infection of the intervertebral disc?

The primary cause is usually bacterial infection, often stemming from hematogenous spread from other infections or direct extension from adjacent osteomyelitis.

How is pyogenic discitis diagnosed?

Diagnosis is typically made through clinical evaluation, imaging studies such as MRI or CT scans, and microbiological cultures.

What are the treatment options for this condition?

Treatment generally involves antibiotics and may require surgical intervention to drain abscesses or debride infected tissue.