Traumatic spondylopathy, sacral and sacrococcygeal region
ICD-10 M48.38 is a billable code used to indicate a diagnosis of traumatic spondylopathy, sacral and sacrococcygeal region.
Traumatic spondylopathy refers to a condition affecting the vertebrae in the sacral and sacrococcygeal regions, typically resulting from trauma or injury. This condition can manifest as pain, inflammation, and structural changes in the spine due to direct impact or stress. The sacral region consists of five fused vertebrae that form the base of the spine, while the sacrococcygeal region includes the coccyx or tailbone. Patients may experience symptoms such as localized pain, reduced mobility, and neurological deficits if nerve roots are affected. Diagnosis often involves imaging studies like X-rays, MRI, or CT scans to assess the extent of injury and rule out other conditions such as ankylosing spondylitis, which is a chronic inflammatory disease leading to fusion of the spine, or spinal stenosis, characterized by narrowing of the spinal canal. Effective management may include physical therapy, pain management, and in severe cases, surgical intervention. Accurate coding is essential for proper treatment reimbursement and tracking of patient outcomes.
Detailed imaging reports, surgical notes, and physical examination findings.
Post-traumatic evaluations, pre-operative assessments for spinal surgery.
Ensure clarity in documenting the mechanism of injury and any associated neurological deficits.
Functional assessments, treatment plans, and progress notes.
Rehabilitation following spinal trauma, management of chronic pain.
Documenting the impact of the condition on daily activities and quality of life.
Used in cases of severe traumatic spondylopathy requiring surgical intervention.
Operative reports detailing the procedure and indications for surgery.
Orthopedic surgeons must document the rationale for surgical intervention clearly.
The primary cause is trauma to the spine, which can occur from falls, accidents, or direct impacts.
Diagnosis is made through a combination of patient history, physical examination, and imaging studies such as X-rays or MRI.
Treatment may include physical therapy, pain management, and in severe cases, surgical intervention.
Yes, if not properly managed, it can lead to chronic pain, mobility issues, and potential neurological deficits.
