Other specified inflammatory spondylopathies, occipito-atlanto-axial region
ICD-10 M46.81 is a billable code used to indicate a diagnosis of other specified inflammatory spondylopathies, occipito-atlanto-axial region.
M46.81 refers to inflammatory spondylopathies that specifically affect the occipito-atlanto-axial region of the spine. This condition is characterized by inflammation of the vertebrae in the upper cervical spine, which can lead to pain, stiffness, and reduced mobility. Inflammatory spondylopathies encompass a range of disorders, including ankylosing spondylitis, which primarily affects the sacroiliac joints and can extend to the cervical spine. Patients may present with chronic neck pain, morning stiffness, and neurological symptoms if spinal stenosis occurs due to inflammation or structural changes. Diagnosis typically involves clinical evaluation, imaging studies such as MRI or CT scans, and laboratory tests to identify inflammatory markers. Treatment may include anti-inflammatory medications, physical therapy, and in severe cases, surgical intervention. Accurate coding is essential for proper management and reimbursement, as these conditions can significantly impact a patient's quality of life and functional abilities.
Detailed history of symptoms, physical examination findings, and laboratory results.
Patients presenting with chronic neck pain and stiffness, particularly in younger adults.
Documentation should include the duration of symptoms and response to treatment.
Imaging results, surgical notes if applicable, and functional assessments.
Patients requiring surgical intervention for severe spinal stenosis due to inflammatory changes.
Ensure that the surgical necessity is clearly documented to support coding.
Used to evaluate inflammatory changes in the occipito-atlanto-axial region.
MRI report must be included in the patient's medical record.
Rheumatologists and orthopedic surgeons should ensure imaging is relevant to the diagnosis.
Common symptoms include chronic neck pain, stiffness, and potential neurological symptoms due to inflammation or stenosis in the cervical spine.
