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v1.0.0
ICD-10 Guide
ICD-10 CodesM41.50

M41.50

Billable

Other secondary scoliosis, site unspecified

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

Code Description

ICD-10 M41.50 is a billable code used to indicate a diagnosis of other secondary scoliosis, site unspecified.

Key Diagnostic Point:

M41.50 refers to a type of scoliosis that is secondary to other underlying conditions, where the specific site of the curvature in the spine is not specified. Scoliosis is characterized by an abnormal lateral curvature of the spine, which can lead to various complications, including pain, reduced lung capacity, and impaired mobility. Secondary scoliosis can arise from a variety of causes, including neuromuscular disorders, congenital anomalies, or as a result of trauma. Unlike idiopathic scoliosis, which has no known cause, secondary scoliosis is often associated with identifiable conditions such as muscular dystrophy or cerebral palsy. The management of secondary scoliosis may involve physical therapy, bracing, or surgical interventions such as spinal fusion, depending on the severity of the curvature and the underlying condition. Accurate coding is essential for appropriate treatment planning and reimbursement, as well as for tracking the prevalence of scoliosis in the population.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Variety of underlying conditions leading to secondary scoliosis
  • Need for precise documentation of the underlying cause
  • Potential for multiple codes to describe the condition
  • Variability in clinical presentation and treatment options

Audit Risk Factors

  • Inadequate documentation of the underlying condition
  • Failure to specify the type of scoliosis
  • Incorrect coding of associated conditions
  • Lack of clarity in treatment plans

Specialty Focus

Medical Specialties

Orthopedic Surgery

Documentation Requirements

Detailed clinical notes on the patient's history, physical examination findings, and imaging results.

Common Clinical Scenarios

Patients presenting with back pain and a noticeable spinal curvature, often requiring surgical intervention.

Billing Considerations

Ensure that the underlying cause of scoliosis is documented to support the use of M41.50.

Physical Medicine and Rehabilitation

Documentation Requirements

Comprehensive assessments of functional limitations and treatment plans.

Common Clinical Scenarios

Patients with scoliosis due to neuromuscular disorders requiring rehabilitation services.

Billing Considerations

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

Coding Guidelines

Inclusion Criteria

Use M41.50 When
  • According to ICD
  • 10 guidelines, M41
  • 50 should be used when the scoliosis is secondary to another condition and the specific site is not documented
  • Coders must ensure that the underlying cause is clearly stated in the medical record to justify the use of this code

Exclusion Criteria

Do NOT use M41.50 When
No specific exclusions found.

Related ICD-10 Codes

Related CPT Codes

22612CPT Code

Spinal fusion, posterior technique

Clinical Scenario

Used in surgical correction of severe scoliosis.

Documentation Requirements

Operative report detailing the procedure and indication.

Specialty Considerations

Orthopedic surgeons must document the rationale for surgery.

ICD-10 Impact

Diagnostic & Documentation Impact

Enhanced Specificity

ICD-10 Improvements

The transition to ICD-10 has allowed for greater specificity in coding scoliosis, including the ability to capture secondary causes. This has improved the accuracy of data collection and reimbursement processes.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for greater specificity in coding scoliosis, including the ability to capture secondary causes. This has improved the accuracy of data collection 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 primary and secondary scoliosis?

Primary scoliosis has no identifiable cause, while secondary scoliosis is due to an underlying condition such as muscular dystrophy or trauma.