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ICD-10 Guide
ICD-10 CodesM46.3

M46.3

Billable

Infection of intervertebral disc (pyogenic)

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

Code Description

ICD-10 M46.3 is a billable code used to indicate a diagnosis of infection of intervertebral disc (pyogenic).

Key Diagnostic Point:

Infection of the intervertebral disc, commonly referred to as discitis, is a serious condition characterized by the inflammation of the disc space due to bacterial infection. Pyogenic discitis is often caused by hematogenous spread from distant infections, such as osteomyelitis or skin infections, or can occur post-operatively. Patients typically present with severe back pain, fever, and neurological deficits depending on the extent of the infection and any associated spinal involvement. Diagnosis is confirmed through imaging studies, such as MRI, which reveal disc space narrowing, edema, and possible abscess formation. Treatment usually involves prolonged antibiotic therapy and may require surgical intervention to debride infected tissue or stabilize the spine. The condition can lead to significant morbidity if not promptly recognized and treated, making accurate coding essential for appropriate management and reimbursement.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Differentiating between pyogenic and non-pyogenic infections.
  • Need for comprehensive documentation of clinical findings.
  • Potential overlap with other spinal conditions like spondylitis.
  • Variability in presentation and diagnostic criteria.

Audit Risk Factors

  • Inadequate documentation of the infectious agent.
  • Failure to document the severity of symptoms.
  • Lack of imaging results in the medical record.
  • Misclassification of the infection type.

Specialty Focus

Medical Specialties

Orthopedic Surgery

Documentation Requirements

Detailed operative notes, imaging results, and post-operative care plans.

Common Clinical Scenarios

Surgical intervention for discitis, management of spinal abscesses.

Billing Considerations

Ensure clarity in distinguishing between surgical and non-surgical cases.

Infectious Disease

Documentation Requirements

Comprehensive history of present illness, laboratory results, and treatment plans.

Common Clinical Scenarios

Management of pyogenic infections, antibiotic stewardship.

Billing Considerations

Documenting the source of infection and response to treatment is critical.

Coding Guidelines

Inclusion Criteria

Use M46.3 When
  • According to ICD
  • 10 coding guidelines, M46
  • 3 should be used when there is clear documentation of a pyogenic infection of the intervertebral disc
  • It is essential to include details about the causative organism, if known, and any associated complications

Exclusion Criteria

Do NOT use M46.3 When
No specific exclusions found.

Related ICD-10 Codes

Related CPT Codes

63030CPT Code

Laminectomy, facetectomy, and/or foraminotomy

Clinical Scenario

Used in cases where surgical intervention is required for discitis.

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 conditions like pyogenic discitis, improving the accuracy of patient records and reimbursement processes.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of conditions like pyogenic discitis, improving the accuracy of patient records 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 are the common causes of pyogenic discitis?

Common causes include hematogenous spread from other infections, post-surgical infections, and direct inoculation during procedures.