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ICD-10 Guide
ICD-10 CodesM48.08

M48.08

Billable

Spinal stenosis, sacral and sacrococcygeal region

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

Code Description

ICD-10 M48.08 is a billable code used to indicate a diagnosis of spinal stenosis, sacral and sacrococcygeal region.

Key Diagnostic Point:

Spinal stenosis in the sacral and sacrococcygeal region refers to the narrowing of the spinal canal in the lower part of the spine, which can lead to compression of the spinal cord and nerves. This condition can result from various factors, including degenerative changes, congenital anomalies, trauma, or inflammatory diseases such as ankylosing spondylitis. Symptoms may include lower back pain, numbness, tingling, and weakness in the legs, as well as bowel and bladder dysfunction in severe cases. Diagnosis typically involves imaging studies such as MRI or CT scans to visualize the degree of stenosis and its impact on surrounding structures. Treatment options may range from conservative management, including physical therapy and pain management, to surgical interventions like laminectomy or spinal fusion, depending on the severity of symptoms and the underlying cause of the stenosis.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Differentiating between types of spinal stenosis (e.g., congenital vs. acquired)
  • Identifying the specific region affected (sacral vs. lumbar vs. cervical)
  • Documenting associated conditions such as ankylosing spondylitis or other inflammatory spine diseases
  • Understanding the implications of co-existing conditions that may affect treatment and coding

Audit Risk Factors

  • Inadequate documentation of symptoms and their impact on daily activities
  • Failure to specify the exact location of stenosis
  • Misclassification of the type of stenosis (e.g., degenerative vs. inflammatory)
  • Lack of supporting imaging studies in the medical record

Specialty Focus

Medical Specialties

Orthopedic Surgery

Documentation Requirements

Detailed operative reports, imaging studies, and pre-operative assessments.

Common Clinical Scenarios

Patients presenting with severe back pain and neurological deficits requiring surgical intervention.

Billing Considerations

Ensure clear documentation of the surgical approach and any complications.

Rheumatology

Documentation Requirements

Comprehensive history of inflammatory symptoms, laboratory results, and imaging findings.

Common Clinical Scenarios

Patients with ankylosing spondylitis presenting with new onset of neurological symptoms.

Billing Considerations

Document the relationship between inflammatory conditions and spinal stenosis.

Coding Guidelines

Inclusion Criteria

Use M48.08 When
  • Follow the official ICD
  • CM coding guidelines, ensuring accurate documentation of the condition's severity and any associated diagnoses
  • Include imaging results and clinical findings that support the diagnosis

Exclusion Criteria

Do NOT use M48.08 When
No specific exclusions found.

Related ICD-10 Codes

Related CPT Codes

63030CPT Code

Laminectomy, decompression of spinal cord

Clinical Scenario

Used when surgical intervention is required for spinal stenosis.

Documentation Requirements

Operative report detailing the procedure and indication for surgery.

Specialty Considerations

Orthopedic surgeons must document the extent of stenosis and any neurological deficits.

ICD-10 Impact

Diagnostic & Documentation Impact

Enhanced Specificity

ICD-10 Improvements

The transition to ICD-10 has allowed for more specific coding of spinal conditions, including spinal stenosis, which enhances the ability to capture the complexity of these cases and improve patient care.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of spinal conditions, including spinal stenosis, which enhances the ability to capture the complexity of these cases and improve patient care.

Reimbursement & Billing Impact

The transition to ICD-10 has allowed for more specific coding of spinal conditions, including spinal stenosis, which enhances the ability to capture the complexity of these cases and improve patient care.

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 symptoms of spinal stenosis?

Common symptoms include lower back pain, numbness or tingling in the legs, weakness, and in severe cases, bowel or bladder dysfunction.

How is spinal stenosis diagnosed?

Diagnosis typically involves a thorough clinical evaluation followed by imaging studies such as MRI or CT scans to assess the degree of stenosis.

What treatment options are available for spinal stenosis?

Treatment options range from conservative management, including physical therapy and medications, to surgical interventions such as laminectomy or spinal fusion, depending on the severity of symptoms.