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ICD-10 Guide
ICD-10 CodesM48.11

M48.11

Billable

Ankylosing hyperostosis [Forestier], occipito-atlanto-axial region

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

Code Description

ICD-10 M48.11 is a billable code used to indicate a diagnosis of ankylosing hyperostosis [forestier], occipito-atlanto-axial region.

Key Diagnostic Point:

Ankylosing hyperostosis, also known as Forestier's disease, is characterized by calcification and ossification of the anterior longitudinal ligament, primarily affecting the spine. This condition typically manifests in the occipito-atlanto-axial region, leading to stiffness and reduced mobility in the cervical spine. Patients may experience neck pain, headaches, and neurological symptoms due to spinal stenosis or nerve root compression. The condition is often associated with aging and may be exacerbated by inflammatory processes. Diagnosis is usually confirmed through imaging studies, such as X-rays or MRI, which reveal characteristic changes in the spinal structures. Management may include physical therapy, pain management, and in severe cases, surgical intervention to relieve compression or restore mobility. Understanding the clinical implications of this condition is crucial for accurate coding and effective treatment planning.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Differentiation from other spondylopathies
  • Need for precise documentation of symptoms and imaging findings
  • Potential overlap with ankylosing spondylitis
  • Variability in clinical presentation

Audit Risk Factors

  • Inadequate documentation of clinical findings
  • Misdiagnosis due to symptom overlap with other conditions
  • Failure to document imaging results
  • Inconsistent coding practices across specialties

Specialty Focus

Medical Specialties

Rheumatology

Documentation Requirements

Detailed clinical history, imaging reports, and treatment plans.

Common Clinical Scenarios

Patients presenting with chronic neck pain and stiffness, particularly in older adults.

Billing Considerations

Ensure clear documentation of inflammatory markers and imaging findings to support diagnosis.

Orthopedics

Documentation Requirements

Surgical notes, pre-operative assessments, and post-operative follow-up documentation.

Common Clinical Scenarios

Patients requiring surgical intervention for spinal stenosis or severe mobility issues.

Billing Considerations

Document the extent of spinal involvement and any neurological deficits.

Coding Guidelines

Inclusion Criteria

Use M48.11 When
  • Follow official ICD
  • CM guidelines for coding spondylopathies
  • Ensure accurate documentation of the location and severity of symptoms
  • Include imaging results to substantiate the diagnosis

Exclusion Criteria

Do NOT use M48.11 When
No specific exclusions found.

Related ICD-10 Codes

Related CPT Codes

63030CPT Code

Laminectomy, cervical

Clinical Scenario

Performed for decompression due to spinal stenosis from hyperostosis.

Documentation Requirements

Pre-operative imaging and clinical notes detailing symptoms and neurological examination.

Specialty Considerations

Orthopedic surgeons should document the extent of spinal involvement.

ICD-10 Impact

Diagnostic & Documentation Impact

Enhanced Specificity

ICD-10 Improvements

The transition to ICD-10 has allowed for more specific coding of conditions like ankylosing hyperostosis, improving the accuracy of diagnoses and treatment planning.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of conditions like ankylosing hyperostosis, improving the accuracy of diagnoses and treatment planning.

Reimbursement & Billing Impact

The transition to ICD-10 has allowed for more specific coding of conditions like ankylosing hyperostosis, improving the accuracy of diagnoses and treatment planning.

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 ankylosing hyperostosis?

Common symptoms include neck pain, stiffness, headaches, and potential neurological symptoms due to spinal stenosis.

How is ankylosing hyperostosis diagnosed?

Diagnosis is typically made through clinical evaluation and imaging studies, such as X-rays or MRI, which reveal characteristic changes.