Unspecified inflammatory spondylopathy, multiple sites in spine
ICD-10 M46.99 is a billable code used to indicate a diagnosis of unspecified inflammatory spondylopathy, multiple sites in spine.
M46.99 refers to unspecified inflammatory spondylopathy affecting multiple sites in the spine. This condition encompasses a range of inflammatory disorders that primarily affect the vertebral column, leading to pain, stiffness, and potential structural changes. Inflammatory spondylopathies include conditions such as ankylosing spondylitis, which is characterized by chronic inflammation of the spine and sacroiliac joints, often resulting in fusion of the vertebrae. Other inflammatory spine conditions may involve autoimmune processes, infections, or reactive arthritis. Symptoms typically include back pain that improves with activity and worsens with rest, as well as systemic manifestations such as fatigue and weight loss. Diagnosis often involves imaging studies, including X-rays and MRI, to assess inflammation and structural changes in the spine. Treatment may include anti-inflammatory medications, physical therapy, and in some cases, surgical intervention. Accurate coding is essential for appropriate management and reimbursement, as these conditions can significantly impact a patient's quality of life.
Detailed history of symptoms, physical examination findings, and results of imaging studies.
Patients presenting with chronic back pain, stiffness, and a family history of inflammatory arthritis.
Documentation must clearly indicate the inflammatory nature of the condition and any associated systemic symptoms.
Comprehensive assessment of spinal mobility, imaging results, and treatment plans.
Patients with progressive spinal deformities or those requiring surgical intervention for severe cases.
Orthopedic documentation should focus on structural changes and the impact on function.
Used to evaluate inflammatory changes in the spine.
MRI results must be documented in the patient's record.
Rheumatologists and orthopedic surgeons often order these studies.
M46.99 should be used when the specific type of inflammatory spondylopathy is not documented or when the physician has not provided sufficient detail to assign a more specific code.
