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ICD-10 Guide
ICD-10 CodesM41.35

M41.35

Billable

Thoracogenic scoliosis, thoracolumbar region

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

Code Description

ICD-10 M41.35 is a billable code used to indicate a diagnosis of thoracogenic scoliosis, thoracolumbar region.

Key Diagnostic Point:

Thoracogenic scoliosis refers to a type of scoliosis that arises due to abnormalities in the thoracic region of the spine, which can subsequently affect the thoracolumbar region. This condition is characterized by a lateral curvature of the spine that can lead to significant postural changes and functional impairments. The thoracolumbar region is particularly vulnerable due to its transitional nature between the thoracic and lumbar spine, making it a common site for scoliosis development. Patients may present with asymmetry in shoulder height, rib prominence, and varying degrees of back pain. The etiology of thoracogenic scoliosis can include congenital deformities, neuromuscular conditions, or idiopathic factors. Diagnosis typically involves clinical examination and imaging studies such as X-rays or MRI to assess the curvature and any associated spinal deformities. Treatment options may range from observation and physical therapy to surgical interventions, including spinal fusion, depending on the severity of the curvature and the presence of symptoms.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Differentiating between types of scoliosis (idiopathic vs. thoracogenic)
  • Understanding the impact of associated conditions (e.g., congenital anomalies)
  • Variability in clinical presentation and severity among patients
  • Need for precise documentation of curvature measurements and symptoms

Audit Risk Factors

  • Inadequate documentation of the curvature degree and its impact on function
  • Failure to specify the thoracolumbar region in documentation
  • Lack of evidence for conservative treatment prior to surgical intervention
  • Misclassification of scoliosis type leading to incorrect coding

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 accurate measurement of spinal curvature and documentation of functional limitations.

Physical Medicine and Rehabilitation

Documentation Requirements

Comprehensive evaluations including functional assessments and treatment plans.

Common Clinical Scenarios

Patients undergoing conservative management for scoliosis with physical therapy.

Billing Considerations

Documenting the effectiveness of non-surgical interventions and patient progress.

Coding Guidelines

Inclusion Criteria

Use M41.35 When
  • According to ICD
  • 10 coding guidelines, M41
  • 35 should be used when the scoliosis is specifically identified as thoracogenic and affects the thoracolumbar region
  • Coders must ensure that the documentation supports the diagnosis and that any associated conditions are also coded appropriately

Exclusion Criteria

Do NOT use M41.35 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 thoracogenic scoliosis.

Documentation Requirements

Operative report detailing the procedure and indication for surgery.

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. M41.35 provides a clear classification for thoracogenic scoliosis, which can enhance treatment planning and outcomes tracking.

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. M41.35 provides a clear classification for thoracogenic scoliosis, which can enhance treatment planning and outcomes tracking.

Reimbursement & Billing Impact

reimbursement processes. M41.35 provides a clear classification for thoracogenic scoliosis, which can enhance treatment planning and outcomes tracking.

Resources

Clinical References

  • •
    ICD-10-CM Official Guidelines for Coding and Reporting

Coding & Billing References

  • •
    ICD-10-CM Official Guidelines for Coding and Reporting

Frequently Asked Questions

What is the difference between thoracogenic scoliosis and idiopathic scoliosis?

Thoracogenic scoliosis is caused by structural abnormalities in the thoracic region, while idiopathic scoliosis has no known cause and typically arises during adolescence. Accurate coding requires understanding the underlying etiology.