Osteomyelitis of vertebra, site unspecified
ICD-10 M46.20 is a billable code used to indicate a diagnosis of osteomyelitis of vertebra, site unspecified.
Osteomyelitis of the vertebra refers to an infection of the bone within the spinal column, which can lead to significant morbidity if not diagnosed and treated promptly. This condition can arise from various sources, including hematogenous spread from distant infections, direct extension from adjacent soft tissue infections, or post-surgical complications. The vertebrae are particularly susceptible to infection due to their rich vascular supply and the presence of intervertebral discs. Symptoms may include localized pain, fever, and neurological deficits if the spinal cord or nerve roots are affected. Diagnosis typically involves imaging studies such as MRI or CT scans, which can reveal bone edema, abscess formation, or other changes indicative of infection. Laboratory tests may show elevated inflammatory markers. Treatment often requires a combination of antibiotics and, in some cases, surgical intervention to debride infected tissue. The unspecified site designation indicates that the specific vertebra affected is not documented, which can complicate treatment planning and prognosis.
Detailed operative notes, imaging studies, and lab results.
Post-operative infections, trauma-related osteomyelitis.
Ensure clear documentation of the surgical history and any complications.
Comprehensive history of infection, treatment plans, and follow-up notes.
Hematogenous osteomyelitis in patients with systemic infections.
Document underlying conditions that may predispose to infection.
Used when joint aspiration is performed due to infection.
Document the reason for aspiration and findings.
Orthopedic documentation should include joint stability assessments.
Document the clinical presentation, imaging findings, laboratory results, and any treatment provided. Ensure that the diagnosis is clearly linked to the patient's symptoms and history.
