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ICD-10 Guide
ICD-10 CodesM46.45

M46.45

Billable

Discitis, unspecified, thoracolumbar region

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

Code Description

ICD-10 M46.45 is a billable code used to indicate a diagnosis of discitis, unspecified, thoracolumbar region.

Key Diagnostic Point:

Discitis is an inflammatory condition affecting the intervertebral discs, often resulting from infection, trauma, or degenerative changes. In the thoracolumbar region, which encompasses the thoracic and lumbar spine, discitis can lead to significant pain, mobility issues, and neurological deficits if not addressed promptly. The condition may present with symptoms such as localized back pain, fever, and in some cases, neurological symptoms due to spinal cord compression. Diagnosis typically involves imaging studies such as MRI or CT scans, which can reveal disc space narrowing, edema, or abscess formation. Treatment often includes antibiotics if an infection is present, along with pain management and possibly surgical intervention in severe cases. The unspecified nature of this code indicates that the specific cause of the discitis has not been determined, which can complicate treatment and management strategies.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Differentiating between infectious and non-infectious causes of discitis.
  • Need for comprehensive imaging studies to confirm diagnosis.
  • Potential overlap with other spinal conditions like spondylopathies and ankylosing spondylitis.
  • Variability in clinical presentation and symptomatology.

Audit Risk Factors

  • Inadequate documentation of symptoms and clinical findings.
  • Failure to specify the cause of discitis.
  • Lack of imaging results in the medical record.
  • Inconsistent coding with other related diagnoses.

Specialty Focus

Medical Specialties

Orthopedic Surgery

Documentation Requirements

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

Common Clinical Scenarios

Patients presenting with back pain and neurological symptoms requiring surgical intervention.

Billing Considerations

Ensure clear documentation of the surgical approach and findings related to discitis.

Infectious Disease

Documentation Requirements

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

Common Clinical Scenarios

Patients with suspected infectious discitis requiring antibiotic therapy.

Billing Considerations

Document the source of infection and response to treatment for accurate coding.

Coding Guidelines

Inclusion Criteria

Use M46.45 When
  • According to ICD
  • 10 guidelines, M46
  • 45 should be used when the specific cause of discitis is not documented
  • Coders should ensure that all relevant clinical information is captured to support the diagnosis

Exclusion Criteria

Do NOT use M46.45 When
  • Exclusion criteria include cases where the cause of discitis is known and can be coded more specifically

Related ICD-10 Codes

Related CPT Codes

63030CPT Code

Laminectomy, facetectomy, and foraminotomy

Clinical Scenario

Used in cases where discitis leads to spinal stenosis requiring surgical intervention.

Documentation Requirements

Operative report detailing the procedure and indications.

Specialty Considerations

Orthopedic surgeons should ensure clear linkage between the diagnosis of discitis and the surgical procedure performed.

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 capture the nuances of the condition and its causes. This specificity aids in better tracking of treatment outcomes and resource allocation.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of discitis, improving the ability to capture the nuances of the condition and its causes. This specificity aids in better tracking of treatment outcomes and resource allocation.

Reimbursement & Billing Impact

The transition to ICD-10 has allowed for more specific coding of discitis, improving the ability to capture the nuances of the condition and its causes. This specificity aids in better tracking of treatment outcomes and resource allocation.

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, with the specific cause often determining the treatment approach.

How is discitis diagnosed?

Diagnosis typically involves imaging studies such as MRI or CT scans, along with clinical evaluation of symptoms.

What are the treatment options for discitis?

Treatment may include antibiotics for infections, pain management, and in severe cases, surgical intervention.