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v1.0.0
ICD-10 Guide
ICD-10 CodesM46.22

M46.22

Billable

Osteomyelitis of vertebra, cervical region

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

Code Description

ICD-10 M46.22 is a billable code used to indicate a diagnosis of osteomyelitis of vertebra, cervical region.

Key Diagnostic Point:

Osteomyelitis of the cervical vertebrae is an infection of the bone that can result from hematogenous spread, direct extension from adjacent soft tissue infections, or post-surgical complications. This condition is characterized by inflammation of the vertebral body and can lead to significant morbidity if not diagnosed and treated promptly. Symptoms may include localized pain, fever, and neurological deficits depending on the extent of the infection and any associated spinal cord involvement. Imaging studies such as MRI or CT scans are crucial for diagnosis, as they can reveal changes in the vertebrae and surrounding soft tissues. Treatment typically involves antibiotics and may require surgical intervention to debride infected tissue or stabilize the spine. Chronic osteomyelitis can lead to complications such as abscess formation, spinal instability, and in severe cases, sepsis. The management of osteomyelitis in the cervical region requires a multidisciplinary approach, often involving infectious disease specialists, orthopedic surgeons, and neurologists.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Differentiating between osteomyelitis and other spinal conditions such as spondylitis or discitis.
  • Need for precise documentation of the infection's origin (hematogenous vs. contiguous spread).
  • Potential for co-existing conditions such as ankylosing spondylitis complicating the clinical picture.
  • Variability in treatment approaches that may affect coding for associated procedures.

Audit Risk Factors

  • Inadequate documentation of the infection's etiology.
  • Failure to document associated neurological symptoms.
  • Misclassification of the condition as a different type of spondylopathy.
  • Lack of imaging studies to support the diagnosis.

Specialty Focus

Medical Specialties

Orthopedic Surgery

Documentation Requirements

Detailed operative notes, imaging studies, and post-operative follow-up documentation.

Common Clinical Scenarios

Surgical intervention for abscess drainage or spinal stabilization.

Billing Considerations

Ensure documentation reflects the surgical approach and any complications encountered.

Infectious Disease

Documentation Requirements

Comprehensive history of infection, laboratory results, and treatment plans.

Common Clinical Scenarios

Management of antibiotic therapy and monitoring for treatment response.

Billing Considerations

Document the rationale for antibiotic selection and duration of therapy.

Coding Guidelines

Inclusion Criteria

Use M46.22 When
  • Follow the official ICD
  • CM coding guidelines, ensuring accurate documentation of the infection's site and etiology
  • Include any relevant co
  • existing conditions and treatments in the coding process

Exclusion Criteria

Do NOT use M46.22 When
No specific exclusions found.

Related ICD-10 Codes

Related CPT Codes

22554CPT Code

Anterior cervical discectomy and fusion

Clinical Scenario

Used in cases where osteomyelitis leads to instability requiring surgical intervention.

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 more specific coding of osteomyelitis, improving the accuracy of data collection and reimbursement processes. M46.22 provides a clear distinction for cervical osteomyelitis, enhancing clinical understanding and treatment planning.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of osteomyelitis, improving the accuracy of data collection and reimbursement processes. M46.22 provides a clear distinction for cervical osteomyelitis, enhancing clinical understanding and treatment planning.

Reimbursement & Billing Impact

reimbursement processes. M46.22 provides a clear distinction for cervical osteomyelitis, enhancing clinical understanding and treatment planning.

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 are the common causes of cervical osteomyelitis?

Common causes include hematogenous spread from distant infections, direct extension from adjacent infections, and post-surgical complications.

How is cervical osteomyelitis diagnosed?

Diagnosis typically involves clinical evaluation, imaging studies such as MRI or CT scans, and microbiological cultures.

What are the treatment options for cervical osteomyelitis?

Treatment may include antibiotics, surgical debridement, and stabilization procedures depending on the severity and extent of the infection.