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ICD-10 Guide
ICD-10 CodesM46.33

M46.33

Billable

Infection of intervertebral disc (pyogenic), cervicothoracic region

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

Code Description

ICD-10 M46.33 is a billable code used to indicate a diagnosis of infection of intervertebral disc (pyogenic), cervicothoracic region.

Key Diagnostic Point:

Infection of the intervertebral disc, specifically in the cervicothoracic region, is characterized by the presence of pyogenic bacteria leading to inflammation and infection of the disc space. This condition can arise from hematogenous spread, direct extension from adjacent structures, or post-surgical complications. Patients typically present with severe neck pain, radicular symptoms, and possibly systemic signs of infection such as fever. The cervicothoracic region is particularly vulnerable due to its anatomical and functional significance, and infections here can lead to serious complications, including abscess formation and neurological deficits. Diagnosis often involves imaging studies such as MRI, which can reveal disc space narrowing, edema, and enhancement of the disc. Treatment usually requires a combination of antibiotics and, in some cases, surgical intervention to decompress the spinal cord or remove infected tissue. Early recognition and management are crucial to prevent long-term sequelae.

Code Complexity Analysis

Complexity Rating: High

High Complexity

Complexity Factors

  • Differentiating between pyogenic and non-pyogenic infections
  • Need for precise documentation of the infection's origin
  • Potential for overlapping symptoms with other spinal conditions
  • Variability in treatment approaches based on severity

Audit Risk Factors

  • Inadequate documentation of clinical findings
  • Failure to specify the type of infection (pyogenic vs. non-pyogenic)
  • Lack of imaging results in the medical record
  • Misinterpretation of symptoms related to other spinal conditions

Specialty Focus

Medical Specialties

Orthopedic Surgery

Documentation Requirements

Detailed operative notes, imaging results, and follow-up assessments.

Common Clinical Scenarios

Post-operative infections, trauma-related disc infections.

Billing Considerations

Ensure clarity on the surgical history and any prior interventions.

Infectious Disease

Documentation Requirements

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

Common Clinical Scenarios

Management of pyogenic infections in immunocompromised patients.

Billing Considerations

Document the source of infection and any co-morbid conditions.

Coding Guidelines

Inclusion Criteria

Use M46.33 When
  • According to ICD
  • 10 guidelines, M46
  • 33 should be used when there is clear documentation of a pyogenic infection of the intervertebral disc in the cervicothoracic region
  • It is essential to ensure that the infection is not due to other causes, such as tuberculosis or fungal infections, which would require different coding

Exclusion Criteria

Do NOT use M46.33 When
No specific exclusions found.

Related ICD-10 Codes

Related CPT Codes

63030CPT Code

Laminectomy, facetectomy, and foraminotomy

Clinical Scenario

Used in cases where surgical intervention is required for disc infection.

Documentation Requirements

Operative report detailing the procedure and indication.

Specialty Considerations

Orthopedic surgeons must document the rationale for surgery.

ICD-10 Impact

Diagnostic & Documentation Impact

Enhanced Specificity

ICD-10 Improvements

The transition to ICD-10 has allowed for more specific coding of infections, including the ability to differentiate between types of infections and their locations, which enhances the accuracy of patient records and treatment plans.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of infections, including the ability to differentiate between types of infections and their locations, which enhances the accuracy of patient records and treatment plans.

Reimbursement & Billing Impact

The transition to ICD-10 has allowed for more specific coding of infections, including the ability to differentiate between types of infections and their locations, which enhances the accuracy of patient records and treatment plans.

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 in the intervertebral disc?

The primary cause is often bacterial infection, which can occur through hematogenous spread, direct extension from adjacent structures, or post-surgical complications.