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v1.0.0
ICD-10 Guide
ICD-10 CodesM46.32

M46.32

Billable

Infection of intervertebral disc (pyogenic), cervical region

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

Code Description

ICD-10 M46.32 is a billable code used to indicate a diagnosis of infection of intervertebral disc (pyogenic), cervical region.

Key Diagnostic Point:

Infection of the intervertebral disc, specifically in the cervical region, is a serious condition characterized by the presence of pyogenic bacteria within the disc space. This condition can lead to severe pain, neurological deficits, and potential complications such as abscess formation or sepsis. The infection often arises from hematogenous spread, direct extension from adjacent structures, or post-surgical complications. Patients typically present with neck pain, fever, and possibly neurological symptoms depending on the extent of the infection and any associated spinal cord involvement. Diagnosis is confirmed through imaging studies such as MRI, which can reveal disc space narrowing, edema, and enhancement of the disc and surrounding tissues. Treatment usually involves a combination of antibiotics and, in some cases, surgical intervention to drain abscesses or debride infected tissue. Early recognition and management are crucial to prevent long-term complications.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Differentiating between pyogenic and non-pyogenic infections
  • Need for precise documentation of the cervical region affected
  • Potential for co-existing conditions such as spondylopathies
  • Variability in clinical presentation and diagnostic criteria

Audit Risk Factors

  • Inadequate documentation of clinical findings
  • Failure to specify the cervical level affected
  • Lack of imaging reports to support diagnosis
  • Misclassification of infection type (pyogenic vs. non-pyogenic)

Specialty Focus

Medical Specialties

Orthopedic Surgery

Documentation Requirements

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

Common Clinical Scenarios

Post-operative infections following cervical spine surgery, acute presentations of cervical discitis.

Billing Considerations

Ensure clear documentation of the surgical history and any complications that may affect coding.

Infectious Disease

Documentation Requirements

Comprehensive patient history, laboratory results, and treatment plans.

Common Clinical Scenarios

Patients presenting with fever and neck pain, suspected discitis due to systemic infection.

Billing Considerations

Document the source of infection and any underlying conditions that may predispose the patient to disc infections.

Coding Guidelines

Inclusion Criteria

Use M46.32 When
  • Follow the official ICD
  • CM coding guidelines, ensuring accurate documentation of the infection type and affected region
  • Include any relevant imaging studies and clinical findings to support the diagnosis

Exclusion Criteria

Do NOT use M46.32 When
No specific exclusions found.

Related ICD-10 Codes

Related CPT Codes

63030CPT Code

Laminectomy, cervical

Clinical Scenario

Used in cases where surgical intervention is required to address infection-related complications.

Documentation Requirements

Operative report detailing the procedure and indication for surgery.

Specialty Considerations

Orthopedic surgeons should ensure that the surgical necessity is 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 infections, improving the accuracy of data collection and reimbursement processes. M46.32 provides a clear distinction between types of infections, which is crucial for treatment planning and epidemiological tracking.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of infections, improving the accuracy of data collection and reimbursement processes. M46.32 provides a clear distinction between types of infections, which is crucial for treatment planning and epidemiological tracking.

Reimbursement & Billing Impact

reimbursement processes. M46.32 provides a clear distinction between types of infections, which is crucial for treatment planning and epidemiological tracking.

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 symptoms of cervical disc infection?

Common symptoms include severe neck pain, fever, and neurological deficits such as weakness or numbness in the arms.

How is cervical disc infection diagnosed?

Diagnosis typically involves clinical evaluation, imaging studies like MRI, and microbiological testing to identify the causative organism.