Unspecified inflammatory spondylopathy, sacral and sacrococcygeal region
ICD-10 M46.98 is a billable code used to indicate a diagnosis of unspecified inflammatory spondylopathy, sacral and sacrococcygeal region.
M46.98 refers to unspecified inflammatory spondylopathy affecting the sacral and sacrococcygeal region. This condition encompasses a range of inflammatory diseases that primarily affect the spine, leading to pain, stiffness, and potential deformity. Inflammatory spondylopathies include conditions such as ankylosing spondylitis, which is characterized by chronic inflammation of the spine and the sacroiliac joints, often resulting in fusion of the vertebrae. The sacral and sacrococcygeal region is particularly significant as it can influence mobility and overall quality of life. Patients may present with symptoms such as lower back pain, reduced spinal mobility, and discomfort in the pelvic area. Diagnosis typically involves clinical evaluation, imaging studies, and laboratory tests to rule out other conditions. Treatment may include anti-inflammatory medications, physical therapy, and in some cases, surgical intervention. Accurate coding is essential for appropriate management and reimbursement, as well as for tracking the epidemiology of these conditions.
Detailed history of symptoms, 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 inflammatory markers and response to treatment.
Comprehensive assessment of spinal mobility, imaging studies, and surgical notes if applicable.
Patients with severe spinal deformities or those requiring surgical intervention.
Document the rationale for surgical procedures and any pre-existing conditions.
Used for initial evaluation of suspected inflammatory spondylopathy.
Radiology report and clinical notes indicating the need for imaging.
Ensure that the imaging correlates with the clinical findings.
Use M46.98 when the specific type of inflammatory spondylopathy is not documented or when the clinical picture does not fit any specific diagnosis.
