Unspecified inflammatory spondylopathy, lumbosacral region
ICD-10 M46.97 is a billable code used to indicate a diagnosis of unspecified inflammatory spondylopathy, lumbosacral region.
Unspecified inflammatory spondylopathy in the lumbosacral region refers to a group of inflammatory conditions affecting the spine, particularly in the lower back area. This condition is characterized by inflammation of the vertebrae and surrounding tissues, which can lead to pain, stiffness, and reduced mobility. It may be associated with other inflammatory diseases, such as ankylosing spondylitis, which primarily affects the sacroiliac joints and can lead to fusion of the spine over time. The lumbosacral region is particularly vulnerable due to its weight-bearing function and range of motion. Symptoms often include chronic lower back pain, which may worsen with inactivity and improve with movement. Diagnosis typically involves clinical evaluation, imaging studies, and laboratory tests to rule out other conditions. Treatment may include anti-inflammatory medications, physical therapy, and in some cases, surgical intervention. Accurate coding is essential for proper management and reimbursement, as it reflects the complexity and severity of the patient's condition.
Detailed history of symptoms, physical examination findings, and results from imaging and laboratory tests.
Patients presenting with chronic lower back pain, stiffness, and a family history of inflammatory diseases.
Ensure clear documentation of inflammatory markers and response to treatment.
Comprehensive assessment of spinal alignment, mobility, and functional limitations.
Patients with progressive back pain and mobility issues requiring surgical evaluation.
Document any surgical interventions or referrals to rheumatology for comprehensive care.
When imaging is required to assess for inflammatory changes in the spine.
Document the clinical rationale for the MRI and any prior treatments attempted.
Rheumatologists may require additional lab tests to correlate with imaging findings.
M46.97 is used for unspecified inflammatory spondylopathy, while M45 is specifically for ankylosing spondylitis. Accurate coding depends on the specificity of the diagnosis.
