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ICD-10 Guide
ICD-10 CodesM41.03

M41.03

Billable

Infantile idiopathic scoliosis, cervicothoracic region

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

Code Description

ICD-10 M41.03 is a billable code used to indicate a diagnosis of infantile idiopathic scoliosis, cervicothoracic region.

Key Diagnostic Point:

Infantile idiopathic scoliosis (IIS) is a spinal deformity characterized by an abnormal lateral curvature of the spine that occurs in children aged 0 to 3 years. The cervicothoracic region refers to the area of the spine that includes the cervical and upper thoracic vertebrae. This condition is classified as idiopathic because the exact cause remains unknown, although it is believed to involve a combination of genetic and environmental factors. The curvature can progress rapidly during the early years of life, potentially leading to significant deformity and functional impairment if not monitored and treated appropriately. Clinical evaluation typically includes physical examination, radiographic assessment, and monitoring of spinal curvature over time. Treatment options may vary based on the severity of the curvature and the age of the child, ranging from observation to bracing and, in severe cases, surgical intervention such as spinal fusion. Early diagnosis and intervention are crucial to prevent complications associated with progressive scoliosis.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Variability in presentation and progression of the condition
  • Need for precise documentation of curvature measurements
  • Differentiation from other types of scoliosis
  • Potential for coexisting conditions affecting treatment

Audit Risk Factors

  • Inadequate documentation of curvature measurements
  • Failure to specify the age of onset
  • Misclassification of idiopathic versus secondary scoliosis
  • Lack of follow-up documentation on treatment efficacy

Specialty Focus

Medical Specialties

Pediatric Orthopedics

Documentation Requirements

Detailed clinical notes including physical examination findings, radiographic images, and treatment plans.

Common Clinical Scenarios

Initial diagnosis of scoliosis, monitoring progression, and planning surgical intervention.

Billing Considerations

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

Physical Medicine and Rehabilitation

Documentation Requirements

Assessment of functional limitations and rehabilitation goals.

Common Clinical Scenarios

Rehabilitation post-surgery or bracing, and management of associated pain.

Billing Considerations

Focus on improving quality of life and functional outcomes.

Coding Guidelines

Inclusion Criteria

Use M41.03 When
  • Follow official ICD
  • CM guidelines for coding spinal deformities, ensuring accurate documentation of the condition's severity and treatment
  • Include any relevant coexisting conditions

Exclusion Criteria

Do NOT use M41.03 When
No specific exclusions found.

Related ICD-10 Codes

Related CPT Codes

22800CPT Code

Spinal fusion, posterior technique

Clinical Scenario

Used for surgical correction of severe idiopathic scoliosis.

Documentation Requirements

Operative report detailing the procedure, indications, and post-operative care.

Specialty Considerations

Pediatric orthopedic surgeons must document growth considerations.

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 M41.03, improving the accuracy of data collection and reimbursement processes. It emphasizes the importance of detailed documentation.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of conditions like M41.03, improving the accuracy of data collection and reimbursement processes. It emphasizes the importance of detailed documentation.

Reimbursement & Billing Impact

reimbursement processes. It emphasizes the importance of detailed documentation.

Resources

Clinical References

  • •
    American Academy of Orthopaedic Surgeons (AAOS)

Coding & Billing References

  • •
    American Academy of Orthopaedic Surgeons (AAOS)

Frequently Asked Questions

What is the age range for coding M41.03?

M41.03 is specifically for infants aged 0 to 3 years, as this is when infantile idiopathic scoliosis typically presents.