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v1.0.0
ICD-10 Guide
ICD-10 CodesM46.49

M46.49

Billable

Discitis, unspecified, multiple sites in spine

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

Code Description

ICD-10 M46.49 is a billable code used to indicate a diagnosis of discitis, unspecified, multiple sites in spine.

Key Diagnostic Point:

Discitis is an inflammatory condition affecting the intervertebral discs, often resulting from infection, trauma, or degenerative changes. When classified as unspecified and affecting multiple sites in the spine, it indicates a broader involvement without a clear etiology. Patients may present with severe back pain, fever, and neurological deficits depending on the extent of the inflammation and any associated complications such as abscess formation or spinal instability. The condition can be linked to spondylopathies, including ankylosing spondylitis, which is characterized by chronic inflammation of the spine and sacroiliac joints. Discitis can also occur in conjunction with spinal stenosis, where narrowing of the spinal canal leads to nerve compression. Inflammatory spine conditions often require a multidisciplinary approach for management, including imaging studies, laboratory tests, and possibly surgical intervention. Accurate diagnosis and coding are crucial for appropriate treatment and reimbursement.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Variability in clinical presentation and underlying causes
  • Need for comprehensive documentation to support multiple sites
  • Differentiation from other spinal conditions like spondylitis or stenosis
  • Potential for co-existing conditions that complicate coding

Audit Risk Factors

  • Inadequate documentation of multiple sites affected
  • Failure to specify the underlying cause of discitis
  • Lack of imaging studies to support diagnosis
  • Inconsistent coding with clinical notes

Specialty Focus

Medical Specialties

Orthopedic Surgery

Documentation Requirements

Detailed surgical notes, imaging results, and patient history.

Common Clinical Scenarios

Post-operative infections leading to discitis, trauma-related discitis.

Billing Considerations

Ensure clarity on the surgical site and any complications that may arise.

Rheumatology

Documentation Requirements

Comprehensive patient history, lab results, and imaging studies.

Common Clinical Scenarios

Patients with ankylosing spondylitis presenting with discitis.

Billing Considerations

Document any systemic inflammatory markers and their correlation with discitis.

Coding Guidelines

Inclusion Criteria

Use M46.49 When
  • According to ICD
  • 10 guidelines, M46
  • 49 should be used when the specific site of discitis is not documented, and multiple sites are involved
  • Coders must ensure that the documentation supports the diagnosis and that all relevant clinical information is included

Exclusion Criteria

Do NOT use M46.49 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

Ensure imaging correlates with clinical symptoms.

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 complexity of the condition and its various presentations.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of discitis, improving the ability to capture the complexity of the condition and its various presentations.

Reimbursement & Billing Impact

reimbursement.

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 are the common causes of discitis?

Common causes of discitis include bacterial infections, post-surgical complications, and inflammatory diseases such as ankylosing spondylitis.