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ICD-10 Guide
ICD-10 CodesM41.23

M41.23

Billable

Other idiopathic scoliosis, cervicothoracic region

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

Code Description

ICD-10 M41.23 is a billable code used to indicate a diagnosis of other idiopathic scoliosis, cervicothoracic region.

Key Diagnostic Point:

M41.23 refers to a specific type of idiopathic scoliosis that occurs in the cervicothoracic region of the spine. Idiopathic scoliosis is characterized by an abnormal lateral curvature of the spine that typically develops during adolescence, although it can manifest at any age. The cervicothoracic region encompasses the cervical and upper thoracic vertebrae, which can lead to significant postural changes and potential complications such as respiratory issues, pain, and reduced mobility. The etiology of idiopathic scoliosis remains largely unknown, hence the term 'idiopathic.' Diagnosis is primarily based on clinical examination and imaging studies, such as X-rays, which reveal the degree of curvature and any associated deformities. Treatment options vary depending on the severity of the curvature and may include observation, bracing, or surgical intervention, such as spinal fusion, to correct the deformity and stabilize the spine. Understanding the nuances of this condition is crucial for accurate coding and appropriate management.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Variability in presentation and severity of scoliosis
  • Need for precise documentation of curvature measurements
  • Differentiation from other types of scoliosis (e.g., congenital, neuromuscular)
  • Potential for co-existing spinal conditions

Audit Risk Factors

  • Inadequate documentation of curvature measurements
  • Failure to specify the region of the spine affected
  • Misclassification of idiopathic scoliosis as another type
  • Lack of supporting clinical evidence for treatment decisions

Specialty Focus

Medical Specialties

Orthopedic Surgery

Documentation Requirements

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

Common Clinical Scenarios

Patients presenting with progressive scoliosis requiring surgical intervention.

Billing Considerations

Ensure clear documentation of the degree of curvature and any neurological assessments.

Physical Medicine and Rehabilitation

Documentation Requirements

Functional assessments, treatment plans, and progress notes.

Common Clinical Scenarios

Patients undergoing conservative management with physical therapy.

Billing Considerations

Document the impact of scoliosis on daily activities and quality of life.

Coding Guidelines

Inclusion Criteria

Use M41.23 When
  • According to ICD
  • 10 coding guidelines, M41
  • 23 should be used when the curvature is idiopathic and specifically located in the cervicothoracic region
  • Coders must ensure that the diagnosis is supported by clinical documentation and imaging studies

Exclusion Criteria

Do NOT use M41.23 When
  • Exclusion criteria include scoliosis due to congenital or neuromuscular causes

Related ICD-10 Codes

Related CPT Codes

22558CPT Code

Spinal fusion, cervical

Clinical Scenario

Used in surgical correction of severe idiopathic scoliosis in the cervicothoracic region.

Documentation Requirements

Operative report detailing the procedure and indication for surgery.

Specialty Considerations

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

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. M41.23 provides a clear designation for idiopathic scoliosis in the cervicothoracic region, facilitating better patient management and research.

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. M41.23 provides a clear designation for idiopathic scoliosis in the cervicothoracic region, facilitating better patient management and research.

Reimbursement & Billing Impact

reimbursement processes. M41.23 provides a clear designation for idiopathic scoliosis in the cervicothoracic region, facilitating better patient management and research.

Resources

Clinical References

  • •
    American Academy of Orthopaedic Surgeons (AAOS)
  • •
    Scoliosis Research Society

Coding & Billing References

  • •
    American Academy of Orthopaedic Surgeons (AAOS)
  • •
    Scoliosis Research Society

Frequently Asked Questions

What is the difference between idiopathic scoliosis and other types?

Idiopathic scoliosis has no known cause, while other types may be due to congenital defects, neuromuscular conditions, or degenerative changes.

When should M41.23 be used instead of M41.21 or M41.22?

M41.23 should be used specifically when the curvature is located in the cervicothoracic region, while M41.21 and M41.22 are for thoracic and lumbar regions, respectively.