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ICD-10 Guide
ICD-10 CodesM48.58

M48.58

Billable

Collapsed vertebra, not elsewhere classified, sacral and sacrococcygeal region

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

Code Description

ICD-10 M48.58 is a billable code used to indicate a diagnosis of collapsed vertebra, not elsewhere classified, sacral and sacrococcygeal region.

Key Diagnostic Point:

Collapsed vertebrae in the sacral and sacrococcygeal 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, resulting in collapse. Spinal stenosis, characterized by narrowing of the spinal canal, can exacerbate these conditions by increasing pressure on the vertebrae, leading to further degeneration and potential collapse. Accurate diagnosis and documentation are crucial, as the management of these conditions often involves a multidisciplinary approach, including pain management, physical therapy, and possibly surgical intervention.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Differentiating between various causes of vertebral collapse
  • Understanding the relationship between inflammatory conditions and vertebral integrity
  • Identifying the specific location of the collapse within the sacral region
  • Documenting the clinical significance of the collapse in relation to patient symptoms

Audit Risk Factors

  • Inadequate documentation of the cause of vertebral collapse
  • Failure to specify the location of the collapse
  • Misclassification of the condition as a more specific diagnosis
  • Lack of supporting imaging studies

Specialty Focus

Medical Specialties

Orthopedics

Documentation Requirements

Detailed imaging reports, clinical assessments, and treatment plans.

Common Clinical Scenarios

Patients presenting with back pain and imaging showing vertebral collapse.

Billing Considerations

Ensure that the cause of collapse is clearly documented to avoid misclassification.

Rheumatology

Documentation Requirements

Comprehensive history of inflammatory conditions, lab results, and treatment responses.

Common Clinical Scenarios

Patients with ankylosing spondylitis experiencing new or worsening back pain.

Billing Considerations

Document the relationship between inflammatory markers and vertebral health.

Coding Guidelines

Inclusion Criteria

Use M48.58 When
  • Follow official ICD
  • 10 coding guidelines, ensuring that the diagnosis is supported by clinical documentation
  • The code should be used when vertebral collapse is confirmed and not classified elsewhere

Exclusion Criteria

Do NOT use M48.58 When
  • Exclude conditions that have specific codes

Related ICD-10 Codes

Related CPT Codes

22551CPT Code

Vertebroplasty

Clinical Scenario

Used in cases of vertebral collapse due to osteoporosis or malignancy.

Documentation Requirements

Pre-operative imaging and clinical justification for the procedure.

Specialty Considerations

Orthopedic or interventional radiology documentation must support the need for vertebroplasty.

ICD-10 Impact

Diagnostic & Documentation Impact

Enhanced Specificity

ICD-10 Improvements

The transition to ICD-10 has allowed for more specific coding of vertebral conditions, improving the accuracy of diagnoses and treatment planning. M48.58 provides a distinct classification for collapsed vertebrae in the sacral region, which was less clearly defined in ICD-9.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of vertebral conditions, improving the accuracy of diagnoses and treatment planning. M48.58 provides a distinct classification for collapsed vertebrae in the sacral region, which was less clearly defined in ICD-9.

Reimbursement & Billing Impact

The transition to ICD-10 has allowed for more specific coding of vertebral conditions, improving the accuracy of diagnoses and treatment planning. M48.58 provides a distinct classification for collapsed vertebrae in the sacral region, which was less clearly defined in ICD-9.

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 various factors, including trauma, osteoporosis, malignancy, or inflammatory conditions such as ankylosing spondylitis.