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ICD-10 Guide
ICD-10 CodesM48.53

M48.53

Billable

Collapsed vertebra, not elsewhere classified, cervicothoracic region

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

Code Description

ICD-10 M48.53 is a billable code used to indicate a diagnosis of collapsed vertebra, not elsewhere classified, cervicothoracic region.

Key Diagnostic Point:

Collapsed vertebrae in the cervicothoracic region can occur due to various underlying conditions, including trauma, malignancy, or degenerative diseases. This code is used when the vertebral collapse is not classified under other specific categories. Spondylopathies, such as ankylosing spondylitis, can lead to vertebral collapse due to chronic inflammation and subsequent structural changes in the spine. Inflammatory spine conditions may also contribute to vertebral instability and collapse, particularly in patients with a history of spinal stenosis, which narrows the spinal canal and can lead to increased pressure on the vertebrae. The cervicothoracic region is particularly vulnerable due to its anatomical complexity and the biomechanical stresses it endures. Accurate diagnosis and documentation are crucial for effective treatment planning and coding, as the underlying cause of the collapse significantly influences management strategies.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Differentiating between traumatic and non-traumatic causes of vertebral collapse
  • Understanding the relationship between spondylopathies and vertebral collapse
  • Identifying the specific region of the spine affected
  • Documenting the presence of comorbid conditions that may complicate the diagnosis

Audit Risk Factors

  • Inadequate documentation of the cause of vertebral collapse
  • Failure to specify the cervicothoracic region
  • Misclassification of the condition under a more specific code
  • Lack of supporting clinical evidence for the diagnosis

Specialty Focus

Medical Specialties

Orthopedics

Documentation Requirements

Detailed imaging reports, surgical notes, and history of present illness.

Common Clinical Scenarios

Patients presenting with back pain, neurological deficits, or post-traumatic symptoms.

Billing Considerations

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

Rheumatology

Documentation Requirements

Comprehensive assessment of inflammatory markers, patient history, and physical examination findings.

Common Clinical Scenarios

Patients with known inflammatory conditions presenting with new or worsening spinal symptoms.

Billing Considerations

Document the progression of the disease and any treatment responses.

Coding Guidelines

Inclusion Criteria

Use M48.53 When
  • According to ICD
  • 10 guidelines, M48
  • 53 should be used when the vertebral collapse is not classified elsewhere
  • Coders must ensure that the documentation supports the diagnosis and that the specific region of the spine is clearly identified

Exclusion Criteria

Do NOT use M48.53 When
  • Exclusion criteria include conditions that are specifically coded elsewhere

Related ICD-10 Codes

Related CPT Codes

22551CPT Code

Percutaneous vertebroplasty

Clinical Scenario

Used in cases of vertebral collapse to stabilize the vertebra.

Documentation Requirements

Pre-operative imaging and assessment of vertebral stability.

Specialty Considerations

Orthopedic surgeons must document the indication for the procedure clearly.

ICD-10 Impact

Diagnostic & Documentation Impact

Enhanced Specificity

ICD-10 Improvements

The transition to ICD-10 has allowed for more specific coding of conditions like vertebral collapse, improving the granularity of data for research and treatment outcomes. M48.53 provides a clear classification for cases that do not fit into other categories, enhancing the accuracy of patient records.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of conditions like vertebral collapse, improving the granularity of data for research and treatment outcomes. M48.53 provides a clear classification for cases that do not fit into other categories, enhancing the accuracy of patient records.

Reimbursement & Billing Impact

The transition to ICD-10 has allowed for more specific coding of conditions like vertebral collapse, improving the granularity of data for research and treatment outcomes. M48.53 provides a clear classification for cases that do not fit into other categories, enhancing the accuracy of patient records.

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 primary cause of a collapsed vertebra?

Collapsed vertebrae can result from trauma, malignancy, osteoporosis, or chronic inflammatory conditions such as ankylosing spondylitis.