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ICD-10 Guide
ICD-10 CodesM43.04

M43.04

Billable

Spondylolysis, thoracic region

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

Code Description

ICD-10 M43.04 is a billable code used to indicate a diagnosis of spondylolysis, thoracic region.

Key Diagnostic Point:

Spondylolysis is a defect in the pars interarticularis of the vertebra, which can lead to instability and pain in the thoracic region of the spine. This condition is often caused by repetitive stress or trauma, particularly in athletes, and can manifest as lower back pain, muscle spasms, and limited mobility. In the thoracic region, spondylolysis may contribute to spinal deformities such as scoliosis, kyphosis, or lordosis, which can further complicate the clinical picture. Diagnosis typically involves imaging studies such as X-rays, MRI, or CT scans to visualize the defect and assess any associated spinal deformities. Treatment may include conservative measures like physical therapy, bracing, or pain management, but in severe cases, surgical intervention such as spinal fusion may be necessary to stabilize the affected vertebrae and alleviate symptoms.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Variability in presentation and symptoms among patients
  • Potential for associated spinal deformities complicating diagnosis
  • Need for precise imaging documentation
  • Differentiation from other spinal conditions

Audit Risk Factors

  • Inadequate documentation of imaging studies
  • Failure to document associated spinal deformities
  • Misclassification of the severity of the condition
  • Lack of clarity in treatment plans

Specialty Focus

Medical Specialties

Orthopedic Surgery

Documentation Requirements

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

Common Clinical Scenarios

Patients presenting with chronic back pain and imaging-confirmed spondylolysis.

Billing Considerations

Ensure that all surgical interventions are clearly documented, including indications for surgery and post-operative care.

Physical Medicine and Rehabilitation

Documentation Requirements

Comprehensive evaluations, treatment plans, and progress notes.

Common Clinical Scenarios

Patients undergoing rehabilitation for pain management and functional improvement.

Billing Considerations

Document the patient's response to therapy and any changes in treatment plans.

Coding Guidelines

Inclusion Criteria

Use M43.04 When
  • According to ICD
  • 10 guidelines, M43
  • 04 should be used when there is a confirmed diagnosis of spondylolysis in the thoracic region
  • Coders should ensure that the diagnosis is supported by imaging and that any associated conditions are documented

Exclusion Criteria

Do NOT use M43.04 When
  • Exclusion criteria include conditions that do not involve the thoracic region or are not classified as spondylolysis

Related ICD-10 Codes

Related CPT Codes

22612CPT Code

Spinal fusion, thoracic

Clinical Scenario

Used when surgical intervention is required for spondylolysis.

Documentation Requirements

Surgical notes, pre-operative assessments, and post-operative care documentation.

Specialty Considerations

Orthopedic surgeons must ensure all indications for surgery are clearly documented.

ICD-10 Impact

Diagnostic & Documentation Impact

Enhanced Specificity

ICD-10 Improvements

The transition to ICD-10 has allowed for more specific coding of spondylolysis, improving the accuracy of data collection and reimbursement processes. This specificity helps in better tracking of treatment outcomes and resource allocation.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of spondylolysis, improving the accuracy of data collection and reimbursement processes. This specificity helps in better tracking of treatment outcomes and resource allocation.

Reimbursement & Billing Impact

reimbursement processes. This specificity helps in better tracking of treatment outcomes and resource allocation.

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 imaging studies are required to support the diagnosis of M43.04?

Imaging studies such as X-rays, MRI, or CT scans are essential to confirm the diagnosis of spondylolysis in the thoracic region and should be documented in the patient's medical record.