Spinal stenosis
ICD-10 M48.0 is a billable code used to indicate a diagnosis of spinal stenosis.
Spinal stenosis refers to the narrowing of the spinal canal, which can lead to compression of the spinal cord and nerves. This condition can occur in any part of the spine but is most commonly seen in the lumbar and cervical regions. The narrowing can be caused by various factors, including degenerative changes associated with aging, herniated discs, thickened ligaments, and bone spurs. Symptoms may include pain, numbness, tingling, and weakness in the limbs, which can significantly impact mobility and quality of life. In some cases, spinal stenosis can be associated with inflammatory spine conditions such as ankylosing spondylitis, where chronic inflammation leads to structural changes in the spine. Diagnosis typically involves imaging studies such as MRI or CT scans to visualize the extent of the stenosis and its effects on surrounding structures. Treatment options range from conservative management, including physical therapy and pain management, to surgical interventions aimed at decompressing the affected areas.
Detailed imaging reports, clinical notes on physical examination findings, and treatment plans.
Patients presenting with lower back pain, radiculopathy, or neurogenic claudication.
Ensure that the documentation clearly states the location and severity of stenosis, as well as any associated neurological deficits.
Comprehensive history of inflammatory symptoms, lab results, and imaging studies.
Patients with ankylosing spondylitis presenting with spinal stiffness and pain.
Document the relationship between inflammatory conditions and spinal stenosis, including any treatment for underlying inflammatory disease.
Performed for severe spinal stenosis causing neurological deficits.
Operative report detailing the procedure and indication for surgery.
Orthopedic surgeons must document the specific levels treated.
Common symptoms include pain, numbness, tingling, and weakness in the legs or arms, often worsening with activity and improving with rest.
