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ICD-10 Guide
ICD-10 CodesM48.33

M48.33

Billable

Traumatic spondylopathy, cervicothoracic region

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

Code Description

ICD-10 M48.33 is a billable code used to indicate a diagnosis of traumatic spondylopathy, cervicothoracic region.

Key Diagnostic Point:

Traumatic spondylopathy in the cervicothoracic region refers to a condition characterized by damage to the vertebrae and surrounding structures in the neck and upper back due to trauma. This can result from various incidents such as falls, motor vehicle accidents, or sports injuries. The condition may manifest as pain, stiffness, and reduced mobility in the affected area. Clinically, it may present with neurological symptoms if spinal cord compression occurs, leading to radiculopathy or myelopathy. Diagnosis typically involves imaging studies such as X-rays, MRI, or CT scans to assess the extent of the injury and rule out other conditions like ankylosing spondylitis or spinal stenosis. Treatment may include conservative management with physical therapy, pain management, and in severe cases, surgical intervention. Understanding the nuances of traumatic spondylopathy is crucial for accurate coding and appropriate patient management.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Differentiating between traumatic and non-traumatic spondylopathies
  • Identifying the specific location of the injury (cervicothoracic region)
  • Potential overlap with other spinal conditions like ankylosing spondylitis
  • Need for detailed documentation of trauma history

Audit Risk Factors

  • Inadequate documentation of trauma history
  • Failure to specify the exact location of the injury
  • Misclassification of the type of spondylopathy
  • Lack of imaging studies to support diagnosis

Specialty Focus

Medical Specialties

Orthopedics

Documentation Requirements

Detailed notes on the mechanism of injury, physical examination findings, and imaging results.

Common Clinical Scenarios

Patients presenting with neck pain following trauma, with or without neurological symptoms.

Billing Considerations

Ensure that all imaging studies are documented and correlate with clinical findings.

Neurology

Documentation Requirements

Neurological examination findings, including any deficits or symptoms related to spinal cord involvement.

Common Clinical Scenarios

Patients with radiculopathy or myelopathy following cervical trauma.

Billing Considerations

Document any neurological assessments thoroughly to support coding.

Coding Guidelines

Inclusion Criteria

Use M48.33 When
  • Follow the official ICD
  • CM coding guidelines, ensuring accurate documentation of the traumatic event and its effects on the cervicothoracic region
  • Include any relevant imaging and clinical findings to support the diagnosis

Exclusion Criteria

Do NOT use M48.33 When
No specific exclusions found.

Related ICD-10 Codes

Related CPT Codes

63030CPT Code

Laminectomy, cervical

Clinical Scenario

Performed for decompression of the spinal cord due to traumatic spondylopathy.

Documentation Requirements

Operative report detailing the procedure and indication.

Specialty Considerations

Orthopedic or neurosurgical documentation must clearly correlate with the diagnosis.

ICD-10 Impact

Diagnostic & Documentation Impact

Enhanced Specificity

ICD-10 Improvements

The transition to ICD-10 has allowed for more specific coding of traumatic spondylopathy, improving the accuracy of data collection and reimbursement processes. This specificity aids in better tracking of trauma-related spinal conditions.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of traumatic spondylopathy, improving the accuracy of data collection and reimbursement processes. This specificity aids in better tracking of trauma-related spinal conditions.

Reimbursement & Billing Impact

reimbursement processes. This specificity aids in better tracking of trauma-related spinal conditions.

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 difference between traumatic spondylopathy and ankylosing spondylitis?

Traumatic spondylopathy is caused by an acute injury to the spine, while ankylosing spondylitis is a chronic inflammatory condition that leads to progressive stiffness and fusion of the spine.