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ICD-10 Guide
ICD-10 CodesM41.52

M41.52

Billable

Other secondary scoliosis, cervical region

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

Code Description

ICD-10 M41.52 is a billable code used to indicate a diagnosis of other secondary scoliosis, cervical region.

Key Diagnostic Point:

M41.52 refers to a specific type of scoliosis that occurs in the cervical region of the spine, classified as secondary scoliosis. This condition arises due to underlying factors such as neuromuscular disorders, congenital anomalies, or previous spinal surgeries that alter the normal curvature of the cervical spine. Secondary scoliosis can lead to significant functional impairment, pain, and neurological deficits, depending on the severity and underlying cause. The cervical spine consists of seven vertebrae (C1-C7), and any deviation from the normal alignment can affect the overall biomechanics of the spine, potentially leading to complications such as cervical radiculopathy or myelopathy. Diagnosis typically involves a thorough clinical evaluation, imaging studies such as X-rays or MRI, and assessment of the patient's history. Treatment options may include physical therapy, bracing, or surgical interventions such as spinal fusion, particularly in severe cases where conservative management fails to provide relief or stabilize the condition.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Differentiating between primary and secondary scoliosis
  • Identifying the underlying cause of scoliosis
  • Variability in presentation and severity among patients
  • Need for comprehensive documentation of clinical findings

Audit Risk Factors

  • Inadequate documentation of the underlying cause of scoliosis
  • Failure to document the severity of the condition
  • Misclassification of primary versus secondary scoliosis
  • Lack of imaging studies to support the diagnosis

Specialty Focus

Medical Specialties

Orthopedic Surgery

Documentation Requirements

Detailed operative reports, imaging studies, and pre-operative assessments.

Common Clinical Scenarios

Surgical intervention for severe scoliosis, post-operative follow-up for spinal fusion.

Billing Considerations

Ensure documentation reflects the complexity of the case and any co-existing conditions.

Neurology

Documentation Requirements

Neurological assessments, imaging results, and history of neurological symptoms.

Common Clinical Scenarios

Evaluation of neurological deficits related to cervical scoliosis.

Billing Considerations

Document neurological findings thoroughly to support the diagnosis.

Coding Guidelines

Inclusion Criteria

Use M41.52 When
  • According to ICD
  • 10 coding guidelines, M41
  • 52 should be used when the scoliosis is confirmed to be secondary to another condition
  • Coders must ensure that the underlying cause is documented and that the scoliosis is specifically identified as cervical

Exclusion Criteria

Do NOT use M41.52 When
No specific exclusions found.

Related ICD-10 Codes

Related CPT Codes

22612CPT Code

Spinal fusion, cervical

Clinical Scenario

Used in cases of severe cervical scoliosis requiring surgical intervention.

Documentation Requirements

Operative report detailing the procedure, indications, and post-operative care.

Specialty Considerations

Orthopedic surgeons must document the rationale for surgery and any pre-existing conditions.

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, including secondary scoliosis, which enhances the ability to capture the complexity of these cases and improve patient management.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of scoliosis types, including secondary scoliosis, which enhances the ability to capture the complexity of these cases and improve patient management.

Reimbursement & Billing Impact

reimbursement and to avoid denials.

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 occurs without an identifiable cause, while secondary scoliosis is due to underlying conditions such as neuromuscular disorders or previous surgeries.