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ICD-10 Guide
ICD-10 CodesM46.53

M46.53

Billable

Other infective spondylopathies, cervicothoracic region

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

Code Description

ICD-10 M46.53 is a billable code used to indicate a diagnosis of other infective spondylopathies, cervicothoracic region.

Key Diagnostic Point:

M46.53 refers to other infective spondylopathies affecting the cervicothoracic region of the spine. This condition encompasses a variety of infectious processes that can lead to inflammation and degeneration of the vertebrae in the cervical and thoracic areas. Common causes include bacterial infections, such as osteomyelitis, and viral infections that may lead to spondylitis. Symptoms often include localized pain, stiffness, and potential neurological deficits if the spinal cord or nerve roots are involved. Diagnosis typically involves imaging studies such as MRI or CT scans, along with laboratory tests to identify the infectious agent. Treatment may include antibiotics for bacterial infections, anti-inflammatory medications, and in severe cases, surgical intervention to relieve pressure on the spinal cord or stabilize the spine. Early diagnosis and treatment are crucial to prevent long-term complications, including chronic pain and disability.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Differentiating between infectious and non-infectious spondylopathies
  • Need for comprehensive documentation of symptoms and diagnostic tests
  • Potential overlap with other spinal conditions like ankylosing spondylitis
  • Variability in treatment approaches based on the underlying infection

Audit Risk Factors

  • Inadequate documentation of the infectious agent
  • Failure to specify the location of the infection
  • Lack of clarity in distinguishing between acute and chronic conditions
  • Insufficient evidence of diagnostic imaging or lab results

Specialty Focus

Medical Specialties

Orthopedic Surgery

Documentation Requirements

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

Common Clinical Scenarios

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

Billing Considerations

Ensure clear documentation of the infectious nature of the condition and any surgical findings.

Infectious Disease

Documentation Requirements

Comprehensive lab results, cultures, and treatment plans.

Common Clinical Scenarios

Patients with fever and back pain where an infectious etiology is suspected.

Billing Considerations

Document the specific pathogen identified and the treatment response.

Coding Guidelines

Inclusion Criteria

Use M46.53 When
  • According to ICD
  • 10 guidelines, M46
  • 53 should be used when the condition is specifically identified as an infective spondylopathy in the cervicothoracic region
  • Coders must ensure that the documentation supports the diagnosis and that any relevant imaging or laboratory findings are included

Exclusion Criteria

Do NOT use M46.53 When
No specific exclusions found.

Related ICD-10 Codes

Related CPT Codes

63030CPT Code

Laminectomy, cervical

Clinical Scenario

Performed to relieve pressure from an abscess in the cervicothoracic region.

Documentation Requirements

Operative report detailing the procedure and indication.

Specialty Considerations

Orthopedic surgeons must document the infectious nature of the condition.

ICD-10 Impact

Diagnostic & Documentation Impact

Enhanced Specificity

ICD-10 Improvements

The transition to ICD-10 has allowed for more specific coding of conditions like M46.53, improving the accuracy of data collection and reimbursement processes. This specificity aids in better tracking of infectious spondylopathies and their outcomes.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of conditions like M46.53, improving the accuracy of data collection and reimbursement processes. This specificity aids in better tracking of infectious spondylopathies and their outcomes.

Reimbursement & Billing Impact

reimbursement processes. This specificity aids in better tracking of infectious spondylopathies and their outcomes.

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 infective spondylopathies?

Common causes include bacterial infections such as osteomyelitis, viral infections, and sometimes fungal infections, particularly in immunocompromised patients.