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v1.0.0
ICD-10 Guide
ICD-10 CodesM46.4

M46.4

Billable

Discitis, unspecified

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

Code Description

ICD-10 M46.4 is a billable code used to indicate a diagnosis of discitis, unspecified.

Key Diagnostic Point:

Discitis is an inflammatory condition affecting the intervertebral discs, often resulting from infection, trauma, or degenerative changes. It can lead to severe back pain, fever, and neurological deficits if not treated promptly. The condition may arise in the context of spondylopathies, such as ankylosing spondylitis, where inflammation of the spine can predispose individuals to discitis. Inflammatory spine conditions can also contribute to the development of discitis, as the inflammatory process may extend to the discs. Spinal stenosis, characterized by narrowing of the spinal canal, can exacerbate symptoms associated with discitis due to increased pressure on the spinal cord and nerves. Diagnosis typically involves imaging studies, such as MRI or CT scans, and laboratory tests to identify infectious agents. Treatment may include antibiotics, anti-inflammatory medications, and in severe cases, surgical intervention. The unspecified nature of this code indicates that the specific cause of the discitis is not documented, which can complicate treatment and management strategies.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Variability in clinical presentation and underlying causes
  • Need for comprehensive documentation to specify the nature of the discitis
  • Differentiation from other spinal conditions like spondylitis or spinal stenosis
  • Potential for co-existing conditions that may complicate coding

Audit Risk Factors

  • Insufficient documentation of the underlying cause of discitis
  • Failure to differentiate from other inflammatory spine conditions
  • Inadequate clinical rationale for the chosen treatment plan
  • Lack of follow-up documentation to support ongoing treatment

Specialty Focus

Medical Specialties

Orthopedics

Documentation Requirements

Detailed history of symptoms, imaging results, and treatment plans.

Common Clinical Scenarios

Patients presenting with back pain, fever, and neurological symptoms.

Billing Considerations

Ensure clear documentation of the clinical rationale for imaging and interventions.

Infectious Disease

Documentation Requirements

Laboratory results, culture reports, and response to antibiotic therapy.

Common Clinical Scenarios

Patients with suspected infectious discitis requiring hospitalization.

Billing Considerations

Document the specific infectious agents identified and treatment response.

Coding Guidelines

Inclusion Criteria

Use M46.4 When
  • Follow official ICD
  • CM guidelines for coding discitis, ensuring to document the specific nature of the condition when possible
  • Include any relevant history of spondylopathies or inflammatory spine conditions

Exclusion Criteria

Do NOT use M46.4 When
No specific exclusions found.

Related ICD-10 Codes

Related CPT Codes

73030CPT Code

CT scan of the spine

Clinical Scenario

Used to evaluate suspected discitis.

Documentation Requirements

Document indications for imaging and findings.

Specialty Considerations

Orthopedic specialists should ensure imaging correlates with clinical findings.

ICD-10 Impact

Diagnostic & Documentation Impact

Enhanced Specificity

ICD-10 Improvements

The transition to ICD-10 has allowed for more specific coding of discitis, improving the ability to track and manage this condition. The specificity helps in understanding the epidemiology and treatment outcomes associated with discitis.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of discitis, improving the ability to track and manage this condition. The specificity helps in understanding the epidemiology and treatment outcomes associated with discitis.

Reimbursement & Billing Impact

The transition to ICD-10 has allowed for more specific coding of discitis, improving the ability to track and manage this condition. The specificity helps in understanding the epidemiology and treatment outcomes associated with discitis.

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 discitis?

Discitis can be caused by infections, trauma, or degenerative changes, but in many cases, the specific cause remains unspecified.