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ICD-10 Guide
ICD-10 CodesM46.54

M46.54

Billable

Other infective spondylopathies, thoracic region

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

Code Description

ICD-10 M46.54 is a billable code used to indicate a diagnosis of other infective spondylopathies, thoracic region.

Key Diagnostic Point:

Infective spondylopathies refer to inflammatory conditions of the spine caused by infectious agents, which can lead to significant morbidity. The thoracic region of the spine is particularly susceptible to infections due to its anatomical structure and the presence of various vascular and neural elements. Conditions classified under M46.54 may include infections resulting from bacterial, viral, or fungal pathogens that affect the thoracic vertebrae and surrounding tissues. Symptoms often include localized pain, fever, and neurological deficits depending on the extent of the infection. Diagnosis typically involves imaging studies such as MRI or CT scans, along with laboratory tests to identify the causative organism. Treatment usually requires a combination of antibiotics or antifungal medications, and in some cases, surgical intervention may be necessary to decompress the spinal cord or stabilize the spine. Early recognition and appropriate management are crucial to prevent complications such as abscess formation or chronic pain syndromes.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Differentiating between infective and non-infective spondylopathies
  • Need for precise documentation of the infectious agent
  • Variability in clinical presentation and diagnostic criteria
  • Potential for overlapping symptoms with other spinal conditions

Audit Risk Factors

  • Insufficient documentation of the infectious agent
  • Lack of imaging studies to support diagnosis
  • Inconsistent clinical findings reported
  • Failure to document treatment plans and outcomes

Specialty Focus

Medical Specialties

Infectious Disease

Documentation Requirements

Detailed history of infection, laboratory results, and imaging studies.

Common Clinical Scenarios

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

Billing Considerations

Ensure clarity on the causative organism and treatment response.

Orthopedic Surgery

Documentation Requirements

Surgical notes, pre-operative assessments, and post-operative follow-ups.

Common Clinical Scenarios

Surgical intervention for abscess drainage or spinal stabilization.

Billing Considerations

Document the need for surgery due to infection-related complications.

Coding Guidelines

Inclusion Criteria

Use M46.54 When
  • Follow the official ICD
  • CM coding guidelines, ensuring accurate documentation of the infectious nature of the spondylopathy
  • Include relevant imaging and lab results to substantiate the diagnosis

Exclusion Criteria

Do NOT use M46.54 When
  • Exclude conditions that do not meet the criteria for infective spondylopathies

Related ICD-10 Codes

Related CPT Codes

63030CPT Code

Laminectomy, facetectomy, and foraminotomy

Clinical Scenario

Used in cases of spinal stenosis or infection requiring decompression.

Documentation Requirements

Surgical notes detailing the procedure and indication.

Specialty Considerations

Orthopedic surgeons must document the rationale for surgery.

ICD-10 Impact

Diagnostic & Documentation Impact

Enhanced Specificity

ICD-10 Improvements

The transition to ICD-10 has allowed for more specific coding of infective spondylopathies, improving the accuracy of data collection and reimbursement processes. It has also enhanced the ability to track epidemiological trends in spinal infections.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of infective spondylopathies, improving the accuracy of data collection and reimbursement processes. It has also enhanced the ability to track epidemiological trends in spinal infections.

Reimbursement & Billing Impact

reimbursement processes. It has also enhanced the ability to track epidemiological trends in spinal infections.

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 Staphylococcus aureus, tuberculosis, and fungal infections. Risk factors include immunocompromised states, recent surgeries, and underlying chronic diseases.