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ICD-10 Guide
ICD-10 CodesM41.115

M41.115

Billable

Juvenile idiopathic scoliosis, thoracolumbar region

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

Code Description

ICD-10 M41.115 is a billable code used to indicate a diagnosis of juvenile idiopathic scoliosis, thoracolumbar region.

Key Diagnostic Point:

Juvenile idiopathic scoliosis (JIS) is a form of scoliosis that occurs in children aged 4 to 10 years. It is characterized by an abnormal lateral curvature of the spine that is not attributable to any known cause. The thoracolumbar region refers to the area of the spine that includes both the thoracic and lumbar vertebrae. In JIS, the curvature can progress rapidly during periods of growth, leading to potential complications such as respiratory issues, pain, and cosmetic concerns. Diagnosis typically involves physical examination and imaging studies, such as X-rays, to assess the degree of curvature. Treatment options may include observation, bracing, or surgical intervention, particularly spinal fusion, depending on the severity of the curve and the child's growth potential. Early detection and management are crucial to prevent further deformity and associated complications.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Variability in presentation and progression of scoliosis in children.
  • Need for precise documentation of curvature measurements.
  • Differentiation from other types of scoliosis and spinal deformities.
  • Potential for co-existing conditions that may complicate coding.

Audit Risk Factors

  • Inadequate documentation of curvature measurements.
  • Failure to specify the thoracolumbar region.
  • Lack of clarity on the idiopathic nature of the scoliosis.
  • Inconsistent coding of associated conditions.

Specialty Focus

Medical Specialties

Orthopedic Surgery

Documentation Requirements

Detailed imaging reports, growth assessments, and treatment plans.

Common Clinical Scenarios

Pre-operative assessments for spinal fusion, monitoring of scoliosis progression.

Billing Considerations

Documentation must clearly indicate the need for surgical intervention based on curvature severity.

Pediatrics

Documentation Requirements

Growth charts, physical examination findings, and family history.

Common Clinical Scenarios

Routine check-ups for children with diagnosed scoliosis, referrals for orthopedic evaluation.

Billing Considerations

Must document the idiopathic nature and any associated symptoms or complications.

Coding Guidelines

Inclusion Criteria

Use M41.115 When
  • According to ICD
  • 10 guidelines, M41
  • 115 should be used when the scoliosis is diagnosed as idiopathic and specifically located in the thoracolumbar region
  • Coders must ensure that the diagnosis is supported by appropriate clinical documentation and imaging studies

Exclusion Criteria

Do NOT use M41.115 When
No specific exclusions found.

Related ICD-10 Codes

Related CPT Codes

22612CPT Code

Spinal fusion, posterior technique

Clinical Scenario

Used for surgical correction of severe idiopathic scoliosis.

Documentation Requirements

Operative reports detailing the procedure and indications.

Specialty Considerations

Orthopedic surgeons must document the rationale for surgical intervention.

ICD-10 Impact

Diagnostic & Documentation Impact

Enhanced Specificity

ICD-10 Improvements

The transition to ICD-10 has allowed for more specific coding of juvenile idiopathic scoliosis, improving the accuracy of data collection and reimbursement processes. This specificity helps in tracking treatment outcomes and resource utilization.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of juvenile idiopathic scoliosis, improving the accuracy of data collection and reimbursement processes. This specificity helps in tracking treatment outcomes and resource utilization.

Reimbursement & Billing Impact

reimbursement processes. This specificity helps in tracking treatment outcomes and resource utilization.

Resources

Clinical References

  • •
    American Academy of Orthopaedic Surgeons

Coding & Billing References

  • •
    American Academy of Orthopaedic Surgeons

Frequently Asked Questions

What is the age range for juvenile idiopathic scoliosis?

Juvenile idiopathic scoliosis typically occurs in children aged 4 to 10 years.

How is juvenile idiopathic scoliosis diagnosed?

Diagnosis is made through physical examination and confirmed with imaging studies such as X-rays.

What are the treatment options for juvenile idiopathic scoliosis?

Treatment options include observation, bracing, and surgical intervention, depending on the severity of the curvature.