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v1.0.0
ICD-10 Guide
ICD-10 CodesM41.0

M41.0

Billable

Infantile idiopathic scoliosis

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

Code Description

ICD-10 M41.0 is a billable code used to indicate a diagnosis of infantile idiopathic scoliosis.

Key Diagnostic Point:

Infantile idiopathic scoliosis (IIS) is a spinal deformity characterized by an abnormal lateral curvature of the spine that occurs in children under the age of three. The etiology of this condition remains largely unknown, hence the term 'idiopathic.' IIS is distinct from adolescent idiopathic scoliosis, as it typically presents with a more pronounced curve and can progress rapidly. The curvature may be accompanied by vertebral rotation, leading to asymmetry in the thoracic cage and potential respiratory complications. Diagnosis is primarily clinical, supported by radiographic imaging to assess the degree of curvature and rule out other causes of scoliosis. Treatment options vary based on the severity of the curvature and may include observation, bracing, or surgical intervention such as spinal fusion in cases of significant progression. Early detection and intervention are crucial to prevent long-term complications and improve outcomes.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Variability in presentation and progression of the condition
  • Need for precise measurement of spinal curvature
  • Differentiation from other types of scoliosis
  • Potential for associated conditions requiring additional coding

Audit Risk Factors

  • Inadequate documentation of curvature measurements
  • Failure to document the age of onset
  • Lack of follow-up notes on treatment efficacy
  • Misclassification of idiopathic scoliosis types

Specialty Focus

Medical Specialties

Pediatric Orthopedics

Documentation Requirements

Detailed clinical notes on curvature assessment, treatment plans, and follow-up evaluations.

Common Clinical Scenarios

Initial diagnosis of scoliosis in infants, monitoring progression, and planning surgical interventions.

Billing Considerations

Consideration of growth patterns and potential for curve progression in young children.

Physical Therapy

Documentation Requirements

Progress notes detailing treatment interventions, patient response, and functional outcomes.

Common Clinical Scenarios

Rehabilitation post-surgery or bracing, and management of scoliosis-related discomfort.

Billing Considerations

Focus on functional mobility and strength training to support spinal health.

Coding Guidelines

Inclusion Criteria

Use M41.0 When
  • Follow the official ICD
  • CM guidelines for coding and reporting, ensuring accurate documentation of the condition's severity and treatment
  • Include any associated conditions that may impact treatment

Exclusion Criteria

Do NOT use M41.0 When
No specific exclusions found.

Related ICD-10 Codes

Related CPT Codes

22800CPT Code

Spinal fusion, posterior technique

Clinical Scenario

Used in cases of severe curvature requiring surgical intervention.

Documentation Requirements

Operative report detailing the procedure and indications.

Specialty Considerations

Orthopedic surgeons must document pre-operative assessments and post-operative care.

ICD-10 Impact

Diagnostic & Documentation Impact

Enhanced Specificity

ICD-10 Improvements

The transition to ICD-10 has allowed for more specific coding of scoliosis types, improving the accuracy of data collection and treatment tracking for conditions like M41.0.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of scoliosis types, improving the accuracy of data collection and treatment tracking for conditions like M41.0.

Reimbursement & Billing Impact

The transition to ICD-10 has allowed for more specific coding of scoliosis types, improving the accuracy of data collection and treatment tracking for conditions like M41.0.

Resources

Clinical References

  • •
    American Academy of Orthopaedic Surgeons (AAOS)

Coding & Billing References

  • •
    American Academy of Orthopaedic Surgeons (AAOS)

Frequently Asked Questions

What is the primary treatment for infantile idiopathic scoliosis?

The primary treatment for infantile idiopathic scoliosis may include observation for mild cases, bracing for moderate cases, and surgical intervention for severe cases or those that progress rapidly.