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ICD-10 Guide
ICD-10 CodesM48.12

M48.12

Billable

Ankylosing hyperostosis [Forestier], cervical region

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

Code Description

ICD-10 M48.12 is a billable code used to indicate a diagnosis of ankylosing hyperostosis [forestier], cervical region.

Key Diagnostic Point:

Ankylosing hyperostosis, also known as Forestier's disease, is characterized by calcification and ossification of the anterior longitudinal ligament of the spine, leading to stiffness and reduced mobility. This condition primarily affects the cervical region, resulting in neck pain and potential neurological complications due to spinal canal narrowing. The pathophysiology involves abnormal bone formation, which can be associated with aging and may present with symptoms similar to ankylosing spondylitis, although it is distinct in its etiology and clinical presentation. Patients may experience progressive loss of range of motion in the cervical spine, and in severe cases, this can lead to spinal stenosis, which may necessitate surgical intervention. Diagnosis is typically made through imaging studies, such as X-rays or MRI, which reveal characteristic changes in the cervical spine. Management focuses on symptomatic relief, physical therapy, and monitoring for complications.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Differentiation from ankylosing spondylitis
  • Need for precise documentation of symptoms and imaging findings
  • Potential for overlapping conditions (e.g., spinal stenosis)
  • Variability in presentation and severity among patients

Audit Risk Factors

  • Inadequate documentation of clinical findings
  • Failure to specify the cervical region affected
  • Misclassification with other spondylopathies
  • Lack of imaging studies to support diagnosis

Specialty Focus

Medical Specialties

Rheumatology

Documentation Requirements

Detailed history of symptoms, physical examination findings, and imaging results.

Common Clinical Scenarios

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

Billing Considerations

Differentiating from other inflammatory spine conditions and ensuring comprehensive evaluation of spinal mobility.

Orthopedics

Documentation Requirements

Surgical notes, imaging studies, and pre-operative assessments.

Common Clinical Scenarios

Patients requiring surgical intervention for spinal stenosis due to ankylosing hyperostosis.

Billing Considerations

Documentation of neurological assessments and surgical indications.

Coding Guidelines

Inclusion Criteria

Use M48.12 When
  • According to ICD
  • 10 guidelines, M48
  • 12 should be used when there is clear documentation of ankylosing hyperostosis affecting the cervical region
  • It is important to include details about the patient's symptoms, imaging findings, and any associated conditions

Exclusion Criteria

Do NOT use M48.12 When
No specific exclusions found.

Related ICD-10 Codes

Related CPT Codes

63030CPT Code

Laminectomy, cervical

Clinical Scenario

Used when surgical intervention is required for spinal stenosis due to ankylosing hyperostosis.

Documentation Requirements

Pre-operative assessments, imaging studies, and surgical notes.

Specialty Considerations

Orthopedic surgeons must document the necessity of surgery based on 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 conditions like ankylosing hyperostosis, improving the accuracy of diagnoses and treatment plans.

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 plans.

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 plans.

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 is the primary symptom of ankylosing hyperostosis?

The primary symptom is chronic neck pain and stiffness, which can progress to reduced mobility in the cervical spine.