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ICD-10 Guide
ICD-10 CodesM41.125

M41.125

Billable

Adolescent idiopathic scoliosis, thoracolumbar region

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

Code Description

ICD-10 M41.125 is a billable code used to indicate a diagnosis of adolescent idiopathic scoliosis, thoracolumbar region.

Key Diagnostic Point:

Adolescent idiopathic scoliosis (AIS) is a three-dimensional spinal deformity characterized by lateral curvature of the spine, typically occurring in children and adolescents during their growth spurts. The thoracolumbar region refers to the area of the spine that includes both the thoracic and lumbar vertebrae. This condition is termed 'idiopathic' because the exact cause remains unknown, although genetic and environmental factors may play a role. The curvature can lead to asymmetry in the shoulders, waist, and hips, and may cause discomfort or pain in some cases. Diagnosis is primarily through physical examination and imaging studies such as X-rays, which help determine the degree of curvature. Treatment options vary based on the severity of the curve and the patient's age, ranging from observation and bracing to surgical interventions like spinal fusion. Spinal fusion aims to correct the curvature and stabilize the spine, preventing further progression of the deformity. Early detection and intervention are crucial to managing the condition effectively and improving the quality of life for affected adolescents.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Variability in curvature severity and progression
  • Need for precise documentation of curvature measurements
  • Differentiation from other types of scoliosis
  • Potential for co-existing conditions affecting treatment

Audit Risk Factors

  • Inadequate documentation of curvature measurements
  • Failure to document the patient's growth status
  • Lack of clarity on treatment decisions and outcomes
  • Misclassification of scoliosis type

Specialty Focus

Medical Specialties

Orthopedic Surgery

Documentation Requirements

Detailed imaging reports, surgical notes, and pre-operative assessments.

Common Clinical Scenarios

Surgical intervention for severe scoliosis, monitoring of curve progression in adolescents.

Billing Considerations

Ensure accurate documentation of the Cobb angle and any associated neurological assessments.

Pediatrics

Documentation Requirements

Growth charts, physical examination findings, and family history.

Common Clinical Scenarios

Routine screening for scoliosis in adolescents, referral for orthopedic evaluation.

Billing Considerations

Document any observations of asymmetry and the patient's growth pattern.

Coding Guidelines

Inclusion Criteria

Use M41.125 When
  • Follow the official ICD
  • CM coding guidelines, ensuring accurate documentation of the condition's severity and treatment
  • Include specific details about the curvature and any associated symptoms

Exclusion Criteria

Do NOT use M41.125 When
  • Exclude conditions that may mimic or complicate the diagnosis

Related ICD-10 Codes

Related CPT Codes

22612CPT Code

Spinal fusion, posterior technique

Clinical Scenario

Used for surgical correction of severe scoliosis.

Documentation Requirements

Operative report detailing the procedure and pre-operative assessments.

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 scoliosis types, improving the accuracy of data collection and reimbursement processes. M41.125 provides a clear distinction for adolescent idiopathic scoliosis, facilitating better tracking of treatment outcomes.

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 reimbursement processes. M41.125 provides a clear distinction for adolescent idiopathic scoliosis, facilitating better tracking of treatment outcomes.

Reimbursement & Billing Impact

reimbursement processes. M41.125 provides a clear distinction for adolescent idiopathic scoliosis, facilitating better tracking of treatment outcomes.

Resources

Clinical References

  • •
    American Academy of Orthopaedic Surgeons

Coding & Billing References

  • •
    American Academy of Orthopaedic Surgeons

Frequently Asked Questions

What is the significance of the Cobb angle in scoliosis?

The Cobb angle is a critical measurement used to assess the severity of scoliosis. It quantifies the degree of spinal curvature, guiding treatment decisions and monitoring progression.