Unspecified inflammatory spondylopathy, cervicothoracic region
ICD-10 M46.93 is a billable code used to indicate a diagnosis of unspecified inflammatory spondylopathy, cervicothoracic region.
Unspecified inflammatory spondylopathy in the cervicothoracic region refers to a condition characterized by inflammation of the spine, particularly affecting the cervical and thoracic vertebrae. This condition can manifest as pain, stiffness, and reduced mobility in the neck and upper back. Inflammatory spondylopathies, including ankylosing spondylitis, are autoimmune disorders that primarily affect the spine and the sacroiliac joints, leading to chronic inflammation. Symptoms may include chronic back pain, which improves with exercise but not with rest, and may be accompanied by systemic symptoms such as fatigue and weight loss. Diagnosis often involves imaging studies, such as X-rays or MRI, to assess for inflammation and structural changes in the spine. Treatment typically includes anti-inflammatory medications, physical therapy, and in some cases, disease-modifying antirheumatic drugs (DMARDs). The unspecified nature of this code indicates that the specific type of inflammatory spondylopathy has not been clearly defined, necessitating careful documentation to support the diagnosis.
Detailed clinical history, physical examination findings, imaging results, and treatment plans.
Patients presenting with chronic back pain, stiffness, and a family history of inflammatory arthritis.
Ensure clear documentation of symptoms and response to treatment to support the diagnosis.
Comprehensive assessment of spinal alignment, mobility, and any surgical interventions if applicable.
Patients with severe pain and functional limitations requiring surgical evaluation.
Document any surgical history or interventions that may impact the inflammatory condition.
Used to evaluate inflammatory changes in the cervicothoracic region.
Document the clinical rationale for the MRI and any prior treatments.
Rheumatologists may order this for diagnosis, while orthopedists may use it for surgical planning.
M46.93 is used for unspecified inflammatory spondylopathy, while M45 is specifically for ankylosing spondylitis. Accurate documentation is essential to determine the correct code.
