Discitis, unspecified, lumbar region
ICD-10 M46.46 is a billable code used to indicate a diagnosis of discitis, unspecified, lumbar region.
Discitis is an inflammatory condition affecting the intervertebral discs, often resulting from infection, trauma, or degenerative changes. In the lumbar region, discitis can lead to severe back pain, limited mobility, and neurological deficits if the inflammation compresses surrounding structures. The condition may be acute or chronic and can be caused by bacterial, viral, or fungal infections. Symptoms typically include localized pain, fever, and sometimes neurological symptoms such as weakness or numbness in the legs. Diagnosis is often confirmed through imaging studies such as MRI or CT scans, which can reveal disc space narrowing, edema, or abscess formation. Treatment usually involves antibiotics for infectious causes, anti-inflammatory medications, and in some cases, surgical intervention to relieve pressure on the spinal cord or nerves. The unspecified nature of this code indicates that the specific etiology of the discitis has not been determined, which can complicate treatment and management strategies.
Detailed notes on physical examination findings, imaging results, and treatment plans.
Patients presenting with back pain and neurological symptoms, requiring surgical evaluation.
Ensure that all surgical interventions are well-documented to support coding.
Clear documentation of infectious workup, including lab results and response to treatment.
Patients with suspected infectious discitis requiring antibiotic therapy.
Document the specific organism if identified to support coding for infectious causes.
Used to evaluate suspected discitis.
Imaging reports must be included in the patient's medical record.
Orthopedic and neurology specialties often order these studies.
M46.46 is used for unspecified discitis, while M46.41 is specifically for discitis due to infection. The choice of code depends on whether the etiology has been determined.
