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v1.0.0
ICD-10 Guide
ICD-10 CodesM46.42

M46.42

Billable

Discitis, unspecified, cervical region

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

Code Description

ICD-10 M46.42 is a billable code used to indicate a diagnosis of discitis, unspecified, cervical region.

Key Diagnostic Point:

Discitis is an inflammatory condition affecting the intervertebral discs, often resulting from infection, trauma, or degenerative changes. In the cervical region, discitis can lead to significant pain, reduced mobility, and neurological deficits due to compression of adjacent structures. The condition may arise from hematogenous spread of infection, direct inoculation during procedures, or as a complication of adjacent spondylopathies such as ankylosing spondylitis. Symptoms typically include localized neck pain, stiffness, and in severe cases, radicular pain or myelopathy. Diagnosis is often confirmed through imaging studies such as MRI, which can reveal disc space narrowing, edema, and potential abscess formation. Treatment may involve antibiotics, anti-inflammatory medications, and in some cases, surgical intervention to decompress neural structures or stabilize the spine. Accurate coding is essential for proper management and reimbursement, as discitis can be a complex condition with overlapping symptoms with other spinal disorders.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Differentiating between infectious and non-infectious causes of discitis
  • Need for comprehensive documentation of clinical findings and imaging results
  • Potential overlap with other spinal conditions like ankylosing spondylitis
  • Variability in treatment approaches based on underlying etiology

Audit Risk Factors

  • Insufficient documentation of clinical findings
  • Lack of imaging studies to support diagnosis
  • Inconsistent coding of related conditions
  • Failure to document treatment plans and responses

Specialty Focus

Medical Specialties

Orthopedic Surgery

Documentation Requirements

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

Common Clinical Scenarios

Surgical intervention for discitis, management of complications, and follow-up care.

Billing Considerations

Ensure documentation reflects the severity of the condition and rationale for surgical intervention.

Infectious Disease

Documentation Requirements

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

Common Clinical Scenarios

Management of discitis due to bacterial or fungal infections.

Billing Considerations

Document the source of infection and any comorbid conditions that may affect treatment.

Coding Guidelines

Inclusion Criteria

Use M46.42 When
  • Follow official ICD
  • CM guidelines for coding discitis, ensuring to document the specific location and nature of the condition
  • Include any relevant comorbidities and complications

Exclusion Criteria

Do NOT use M46.42 When
No specific exclusions found.

Related ICD-10 Codes

Related CPT Codes

63030CPT Code

Laminectomy, cervical, for decompression of spinal cord

Clinical Scenario

Used when surgical intervention is required for discitis.

Documentation Requirements

Surgical notes, imaging results, and pre-operative assessments.

Specialty Considerations

Orthopedic surgeons should 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 discitis, improving the accuracy of diagnoses and treatment plans. This specificity aids in better tracking of outcomes and resource allocation.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of discitis, improving the accuracy of diagnoses and treatment plans. This specificity aids in better tracking of outcomes and resource allocation.

Reimbursement & Billing Impact

The transition to ICD-10 has allowed for more specific coding of discitis, improving the accuracy of diagnoses and treatment plans. This specificity aids in better tracking of 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 are the common causes of discitis?

Common causes include bacterial infections, fungal infections, and complications from adjacent spinal conditions such as ankylosing spondylitis.