Unspecified inflammatory spondylopathy, occipito-atlanto-axial region
ICD-10 M46.91 is a billable code used to indicate a diagnosis of unspecified inflammatory spondylopathy, occipito-atlanto-axial region.
Unspecified inflammatory spondylopathy in the occipito-atlanto-axial region refers to a condition characterized by inflammation of the spine, particularly affecting the junction between the occipital bone at the base of the skull and the first two cervical vertebrae (the atlas and axis). This condition can lead to pain, stiffness, and reduced mobility in the neck. Inflammatory spondylopathies encompass a range of disorders, including ankylosing spondylitis, which is a chronic inflammatory disease primarily affecting the axial skeleton. The occipito-atlanto-axial region is critical for head movement and stability, and inflammation here can significantly impact a patient's quality of life. Symptoms may include neck pain, headaches, and neurological deficits if the spinal cord is compressed. Diagnosis typically involves clinical evaluation, imaging studies, and sometimes laboratory tests to identify inflammatory markers. Treatment often includes anti-inflammatory medications, physical therapy, and in some cases, surgical intervention. Accurate coding is essential for appropriate management and reimbursement.
Detailed clinical history, physical examination findings, imaging results, and laboratory tests.
Patients presenting with chronic neck pain, stiffness, and inflammatory markers.
Ensure clear documentation of inflammatory symptoms and response to treatment.
Surgical notes, imaging studies, and pre-operative assessments.
Patients requiring surgical intervention for severe spinal stenosis or instability.
Document the rationale for surgical intervention and any conservative treatments attempted.
Used to evaluate inflammatory changes in the occipito-atlanto-axial region.
Indication for MRI must be clearly documented, including symptoms and prior treatments.
Rheumatologists and orthopedic surgeons should ensure imaging correlates with clinical findings.
M46.91 specifies inflammatory spondylopathy in the occipito-atlanto-axial region, while M46.90 is a more general code for unspecified inflammatory spondylopathy without a specified site.
