Spinal stenosis, thoracic region
ICD-10 M48.04 is a billable code used to indicate a diagnosis of spinal stenosis, thoracic region.
Spinal stenosis in the thoracic region refers to the narrowing of the spinal canal in the thoracic area, which can lead to compression of the spinal cord and nerve roots. This condition can result from various factors, including degenerative changes, congenital anomalies, trauma, or inflammatory diseases such as ankylosing spondylitis. Patients may present with symptoms such as back pain, numbness, weakness, and difficulty walking. The thoracic spine is less commonly affected than the cervical or lumbar regions, but when stenosis occurs, it can significantly impact mobility and quality of life. Diagnosis typically involves imaging studies such as MRI or CT scans to visualize the extent of the stenosis and any associated pathologies. Treatment options may include physical therapy, pain management, and, in severe cases, surgical intervention to relieve pressure on the spinal cord.
Detailed imaging reports, surgical notes, and pre-operative assessments.
Patients presenting with severe back pain and neurological deficits requiring surgical intervention.
Ensure that the surgical approach and specific procedures are clearly documented to support coding.
Comprehensive history of inflammatory conditions, lab results, and imaging studies.
Patients with ankylosing spondylitis presenting with thoracic spinal stenosis.
Document the relationship between inflammatory conditions and spinal stenosis for accurate coding.
Performed to relieve pressure from thoracic spinal stenosis.
Operative report detailing the procedure and indication.
Orthopedic surgeons should ensure clear documentation of the diagnosis and procedure.
Common symptoms include back pain, numbness, weakness in the legs, and difficulty walking. Symptoms may worsen with activity and improve with rest.
