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ICD-10 Guide
ICD-10 CodesM46.92

M46.92

Billable

Unspecified inflammatory spondylopathy, cervical region

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

Code Description

ICD-10 M46.92 is a billable code used to indicate a diagnosis of unspecified inflammatory spondylopathy, cervical region.

Key Diagnostic Point:

Unspecified inflammatory spondylopathy of the cervical region refers to a group of inflammatory conditions affecting the cervical spine that do not have a specific diagnosis. This condition can manifest as pain, stiffness, and reduced mobility in the neck due to inflammation of the vertebrae and surrounding tissues. It may be associated with other inflammatory diseases such as ankylosing spondylitis, which primarily affects the sacroiliac joints and can lead to spinal fusion over time. Inflammatory spondylopathies can also be linked to autoimmune disorders, infections, or other systemic inflammatory conditions. Diagnosis typically involves clinical evaluation, imaging studies like MRI or CT scans, and laboratory tests to rule out other conditions. Treatment may include anti-inflammatory medications, physical therapy, and in some cases, surgical intervention. The unspecified nature of this code indicates that the specific cause of inflammation is not clearly defined, which can complicate treatment and management.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Lack of specificity in diagnosis can lead to misinterpretation.
  • Differentiating between various types of spondylopathy requires thorough clinical documentation.
  • Potential overlap with other inflammatory conditions complicates coding.
  • Need for comprehensive patient history to establish the inflammatory nature.

Audit Risk Factors

  • Insufficient documentation of clinical findings.
  • Inconsistent use of terminology in patient records.
  • Failure to document the patient's history of inflammatory conditions.
  • Lack of imaging studies to support the diagnosis.

Specialty Focus

Medical Specialties

Rheumatology

Documentation Requirements

Detailed patient history, physical examination findings, imaging results, and laboratory tests.

Common Clinical Scenarios

Patients presenting with chronic neck pain, stiffness, and a history of inflammatory diseases.

Billing Considerations

Ensure clear documentation of inflammatory markers and response to treatment.

Orthopedics

Documentation Requirements

Surgical notes, imaging studies, and post-operative follow-up documentation.

Common Clinical Scenarios

Patients requiring surgical intervention for severe spinal stenosis or deformity due to inflammatory spondylopathy.

Billing Considerations

Document the rationale for surgical intervention and any conservative treatments attempted.

Coding Guidelines

Inclusion Criteria

Use M46.92 When
  • Follow the official ICD
  • CM coding guidelines, ensuring that the diagnosis is supported by clinical documentation
  • Include any relevant imaging or laboratory results that confirm the inflammatory nature of the condition

Exclusion Criteria

Do NOT use M46.92 When
  • Exclude codes that specify a known cause of spondylopathy

Related ICD-10 Codes

Related CPT Codes

72148CPT Code

MRI of the cervical spine without contrast

Clinical Scenario

Used to evaluate the extent of inflammation in the cervical spine.

Documentation Requirements

Document the reason for the MRI and any prior treatments attempted.

Specialty Considerations

Rheumatologists and orthopedic surgeons should ensure imaging correlates with clinical findings.

ICD-10 Impact

Diagnostic & Documentation Impact

Enhanced Specificity

ICD-10 Improvements

The transition to ICD-10 has allowed for more detailed coding of inflammatory spondylopathies, improving the ability to track and manage these conditions. M46.92 provides a way to capture unspecified cases, but it is essential to strive for more specific diagnoses when possible.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more detailed coding of inflammatory spondylopathies, improving the ability to track and manage these conditions. M46.92 provides a way to capture unspecified cases, but it is essential to strive for more specific diagnoses when possible.

Reimbursement & Billing Impact

The transition to ICD-10 has allowed for more detailed coding of inflammatory spondylopathies, improving the ability to track and manage these conditions. M46.92 provides a way to capture unspecified cases, but it is essential to strive for more specific diagnoses when possible.

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 should I document to support the use of M46.92?

Document the patient's symptoms, clinical findings, imaging results, and any relevant history of inflammatory conditions to support the diagnosis of unspecified inflammatory spondylopathy.