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ICD-10 Guide
ICD-10 CodesM48.35

M48.35

Billable

Traumatic spondylopathy, thoracolumbar region

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

Code Description

ICD-10 M48.35 is a billable code used to indicate a diagnosis of traumatic spondylopathy, thoracolumbar region.

Key Diagnostic Point:

Traumatic spondylopathy of the thoracolumbar region refers to a condition characterized by damage to the vertebrae and surrounding structures in the thoracic and lumbar spine due to trauma. This can result from various incidents, including falls, motor vehicle accidents, or sports injuries. Clinically, patients may present with back pain, limited mobility, and neurological deficits depending on the severity of the injury. The thoracolumbar region is particularly vulnerable due to its biomechanical properties and the transition between the rigid thoracic spine and the more flexible lumbar spine. Diagnosis typically involves imaging studies such as X-rays, CT scans, or MRIs to assess the extent of vertebral damage and any associated soft tissue injuries. Treatment may include conservative management with physical therapy and pain control, or surgical intervention in cases of significant structural compromise or neurological involvement. Understanding the nuances of traumatic spondylopathy is essential for accurate coding and appropriate management of affected patients.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Differentiating between traumatic and non-traumatic spondylopathies
  • Identifying associated neurological deficits
  • Understanding the specific location of the injury within the thoracolumbar region
  • Documenting the mechanism of injury accurately

Audit Risk Factors

  • Inadequate documentation of the mechanism of injury
  • Failure to document neurological symptoms
  • Misclassification of the injury type (traumatic vs. degenerative)
  • Lack of imaging results in the medical record

Specialty Focus

Medical Specialties

Orthopedics

Documentation Requirements

Detailed descriptions of the injury mechanism, imaging findings, and treatment plans.

Common Clinical Scenarios

Patients presenting with acute back pain following trauma, requiring surgical evaluation.

Billing Considerations

Ensure that all imaging studies are documented and correlate with clinical findings.

Neurology

Documentation Requirements

Assessment of neurological deficits, including sensory and motor function evaluations.

Common Clinical Scenarios

Patients with traumatic spondylopathy presenting with radiculopathy or myelopathy.

Billing Considerations

Document neurological assessments thoroughly to support coding for any associated deficits.

Coding Guidelines

Inclusion Criteria

Use M48.35 When
  • According to ICD
  • 10 guidelines, M48
  • 35 should be used when the spondylopathy is directly linked to a traumatic event
  • Coders must ensure that the documentation supports the diagnosis and that any associated conditions are also coded appropriately

Exclusion Criteria

Do NOT use M48.35 When
No specific exclusions found.

Related ICD-10 Codes

Related CPT Codes

22551CPT Code

Percutaneous vertebroplasty

Clinical Scenario

Used in cases of vertebral compression fractures due to trauma.

Documentation Requirements

Document the indication for the procedure and imaging findings.

Specialty Considerations

Orthopedic surgeons must ensure that the procedure is justified based on the severity of the injury.

ICD-10 Impact

Diagnostic & Documentation Impact

Enhanced Specificity

ICD-10 Improvements

The transition to ICD-10 has allowed for more specific coding of traumatic spondylopathy, improving the accuracy of claims and facilitating better patient management through detailed documentation.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of traumatic spondylopathy, improving the accuracy of claims and facilitating better patient management through detailed documentation.

Reimbursement & Billing Impact

The transition to ICD-10 has allowed for more specific coding of traumatic spondylopathy, improving the accuracy of claims and facilitating better patient management through detailed documentation.

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 is the difference between traumatic spondylopathy and degenerative spondylopathy?

Traumatic spondylopathy is caused by an acute injury, while degenerative spondylopathy results from chronic wear and tear on the spine. Accurate documentation of the injury mechanism is crucial for proper coding.