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v1.0.0
ICD-10 Guide
ICD-10 CodesM41.2

M41.2

Billable

Other idiopathic scoliosis

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

Code Description

ICD-10 M41.2 is a billable code used to indicate a diagnosis of other idiopathic scoliosis.

Key Diagnostic Point:

Other idiopathic scoliosis refers to a type of spinal deformity characterized by an abnormal lateral curvature of the spine that occurs without a known cause. Unlike congenital scoliosis, which is present at birth, or neuromuscular scoliosis, which is associated with conditions like cerebral palsy or muscular dystrophy, idiopathic scoliosis typically develops during childhood or adolescence. The curvature can vary in severity and may progress over time, potentially leading to complications such as back pain, respiratory issues, and reduced quality of life. Diagnosis is primarily based on clinical examination and imaging studies, such as X-rays, which help assess the degree of curvature and its impact on spinal alignment. Treatment options may include observation, bracing, or surgical intervention, such as spinal fusion, depending on the severity of the curvature and the patient's age. Spinal fusion procedures aim to stabilize the spine and prevent further progression of the deformity. The management of idiopathic scoliosis requires a multidisciplinary approach, involving orthopedic surgeons, physical therapists, and sometimes, pain management specialists.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Variability in curvature severity and progression
  • Need for comprehensive imaging documentation
  • Differentiation from other types of scoliosis
  • Potential for surgical intervention documentation

Audit Risk Factors

  • Inadequate documentation of curvature measurements
  • Failure to specify idiopathic nature
  • Lack of follow-up documentation for treatment outcomes
  • Misclassification with other scoliosis types

Specialty Focus

Medical Specialties

Orthopedic Surgery

Documentation Requirements

Detailed imaging reports, surgical notes, and follow-up assessments.

Common Clinical Scenarios

Surgical intervention for severe curvature, bracing recommendations for adolescents.

Billing Considerations

Ensure accurate documentation of curvature angles and progression over time.

Physical Therapy

Documentation Requirements

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

Common Clinical Scenarios

Rehabilitation post-surgery, management of pain and mobility issues.

Billing Considerations

Document specific exercises and their impact on spinal alignment.

Coding Guidelines

Inclusion Criteria

Use M41.2 When
  • Follow official ICD
  • CM guidelines for coding scoliosis, ensuring to document the idiopathic nature and any associated symptoms or treatments
  • Include curvature measurements when applicable

Exclusion Criteria

Do NOT use M41.2 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 report detailing the procedure, indications, and post-operative care.

Specialty Considerations

Orthopedic surgeons must document the rationale for surgery and expected outcomes.

ICD-10 Impact

Diagnostic & Documentation Impact

Enhanced Specificity

ICD-10 Improvements

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

ICD-9 vs ICD-10

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

Reimbursement & Billing Impact

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

Resources

Clinical References

  • •
    American Academy of Orthopaedic Surgeons

Coding & Billing References

  • •
    American Academy of Orthopaedic Surgeons

Frequently Asked Questions

What is the difference between idiopathic scoliosis and congenital scoliosis?

Idiopathic scoliosis occurs without a known cause and typically develops during childhood, while congenital scoliosis is due to structural abnormalities present at birth.