Fatigue fracture of vertebra, sacral and sacrococcygeal region
ICD-10 M48.48 is a billable code used to indicate a diagnosis of fatigue fracture of vertebra, sacral and sacrococcygeal region.
Fatigue fractures of the vertebrae, particularly in the sacral and sacrococcygeal regions, are often the result of repetitive stress or overuse, leading to microtrauma that exceeds the bone's ability to repair itself. These fractures are commonly seen in individuals with underlying conditions such as spondylopathies, ankylosing spondylitis, or spinal stenosis, which can predispose the vertebrae to weakness and increased susceptibility to fractures. Patients may present with localized pain, tenderness, and reduced mobility, often exacerbated by activities that place stress on the spine. Diagnosis typically involves imaging studies such as X-rays, MRI, or CT scans to confirm the presence of a fracture and assess any associated spinal deformities or complications. Management may include conservative treatment options such as rest, physical therapy, and pain management, although surgical intervention may be necessary in cases of severe instability or neurological compromise. Accurate coding is essential for proper reimbursement and to reflect the complexity of the patient's condition.
Detailed imaging reports, treatment plans, and follow-up assessments.
Patients presenting with back pain and a history of repetitive stress injuries.
Ensure that all relevant comorbidities are documented to support the complexity of the case.
Comprehensive history of inflammatory conditions, lab results, and treatment responses.
Patients with ankylosing spondylitis experiencing new onset back pain.
Document the relationship between inflammatory conditions and the risk of fatigue fractures.
Used when joint injections are performed for pain management in patients with fatigue fractures.
Document the joint involved, the procedure performed, and the patient's response.
Orthopedic specialists may frequently perform this procedure in conjunction with fracture management.
A fatigue fracture results from repetitive stress over time, while an acute fracture occurs suddenly due to trauma. Accurate documentation is essential to differentiate between the two for coding purposes.
