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ICD-10 Guide
ICD-10 CodesM41.46

M41.46

Billable

Neuromuscular scoliosis, lumbar region

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

Code Description

ICD-10 M41.46 is a billable code used to indicate a diagnosis of neuromuscular scoliosis, lumbar region.

Key Diagnostic Point:

Neuromuscular scoliosis is a type of scoliosis that arises due to underlying neuromuscular conditions such as cerebral palsy, muscular dystrophy, or spinal muscular atrophy. This condition is characterized by an abnormal lateral curvature of the spine, specifically affecting the lumbar region. The curvature can lead to significant postural deformities and functional impairments, impacting the patient's ability to perform daily activities. Neuromuscular scoliosis often develops as a result of muscle weakness or imbalances, which can cause the spine to curve abnormally. Patients may present with symptoms such as back pain, difficulty in mobility, and respiratory issues due to compromised thoracic capacity. Treatment options may include physical therapy, bracing, and in severe cases, surgical intervention such as spinal fusion to correct the curvature and stabilize the spine. Accurate diagnosis and coding are essential for appropriate management and reimbursement.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Requires understanding of underlying neuromuscular conditions
  • Differentiation from other types of scoliosis
  • Potential for co-existing conditions affecting coding
  • Documentation must specify the severity and impact on function

Audit Risk Factors

  • Inadequate documentation of the underlying neuromuscular condition
  • Failure to specify the severity of scoliosis
  • Lack of evidence for functional impairment
  • Incorrect coding of the spinal region affected

Specialty Focus

Medical Specialties

Orthopedic Surgery

Documentation Requirements

Detailed clinical notes on spinal curvature, physical examination findings, and imaging results.

Common Clinical Scenarios

Patients presenting with progressive scoliosis requiring surgical intervention.

Billing Considerations

Ensure documentation reflects the need for surgical correction and the patient's functional limitations.

Physical Medicine and Rehabilitation

Documentation Requirements

Comprehensive assessment of functional abilities and limitations, treatment plans, and progress notes.

Common Clinical Scenarios

Patients undergoing rehabilitation for scoliosis-related impairments.

Billing Considerations

Document the impact of scoliosis on daily activities and the effectiveness of therapeutic interventions.

Coding Guidelines

Inclusion Criteria

Use M41.46 When
  • Follow the official ICD
  • CM coding guidelines, ensuring that the code is used in conjunction with documentation that supports the diagnosis of neuromuscular scoliosis
  • Include any relevant comorbidities and specify the lumbar region

Exclusion Criteria

Do NOT use M41.46 When
No specific exclusions found.

Related ICD-10 Codes

Related CPT Codes

22612CPT Code

Spinal fusion, lumbar

Clinical Scenario

Used for surgical correction of severe lumbar scoliosis.

Documentation Requirements

Pre-operative assessment, imaging studies, and surgical notes.

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 neuromuscular scoliosis, improving the accuracy of diagnosis and treatment tracking. This specificity aids in better patient management and reimbursement processes.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of neuromuscular scoliosis, improving the accuracy of diagnosis and treatment tracking. This specificity aids in better patient management and reimbursement processes.

Reimbursement & Billing Impact

reimbursement processes.

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 neuromuscular scoliosis and idiopathic scoliosis?

Neuromuscular scoliosis is caused by underlying neuromuscular disorders, while idiopathic scoliosis has no known cause. Accurate coding requires documentation of the underlying condition.