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ICD-10 Coding for Spondyloarthritis(M45.A0, M45.9)

Complete ICD-10-CM coding and documentation guide for Spondyloarthritis. Includes clinical validation requirements, documentation requirements, and coding pitfalls.

Also known as:

Axial SpondyloarthritisAnkylosing SpondylitisNon-radiographic Axial Spondyloarthritis

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Related ICD-10 Code Ranges

Complete code families applicable to Spondyloarthritis

M45-M46Primary Range

Ankylosing spondylitis and other inflammatory spondylopathies

This range includes codes for various forms of spondyloarthritis, including ankylosing spondylitis and non-radiographic axial spondyloarthritis.

Code Comparison: When to Use Each Code

Compare key differences between these codes to ensure accurate selection

CodeDescriptionWhen to UseKey Documentation
M45.A0Non-radiographic axial spondyloarthritisUse when MRI shows sacroiliitis without radiographic changes.
  • BASDAI ≥4
  • MRI sacroiliitis
  • CRP/ESR elevation or HLA-B27+
M45.9Ankylosing spondylitisUse when X-rays confirm sacroiliitis.
  • Modified NY criteria met
  • X-ray sacroiliitis grade ≥2 bilateral

Clinical Decision Support

Always review the patient's clinical documentation thoroughly. When in doubt, choose the more specific code and ensure documentation supports it.

Key Information: ICD-10 code for non-radiographic axial spondyloarthritis

Essential facts and insights about Spondyloarthritis

The ICD-10 code for non-radiographic axial spondyloarthritis is M45.A0, used when MRI shows sacroiliitis without X-ray changes.

Primary ICD-10-CM Codes for spondyloarthritis

M45.A0
Non-radiographic axial spondyloarthritis
Billable Code

Decision Criteria

clinical Criteria

  • MRI shows sacroiliitis without X-ray changes.

documentation Criteria

  • Document inflammatory back pain and MRI findings.

Applicable To

  • Inflammatory back pain
  • Sacroiliitis on MRI without X-ray changes

Excludes

  • Ankylosing spondylitis (M45.9)

Clinical Validation Requirements

  • BASDAI ≥4
  • MRI sacroiliitis
  • CRP/ESR elevation or HLA-B27+

Code-Specific Risks

  • Misclassification if X-ray changes are present

Coding Notes

  • Ensure MRI findings are documented to differentiate from ankylosing spondylitis.
View Full Code Details

Ancillary Codes

Additional codes that should be used in conjunction with the main diagnosis codes when applicable.

Chronic pain due to trauma

G89.21
Use for chronic pain associated with spondyloarthritis.

Other chronic pain

G89.29
Use for chronic pain associated with ankylosing spondylitis.

Differential Codes

Alternative codes to consider when ruling out similar conditions to the primary diagnosis.

Ankylosing spondylitis

M45.9
Use if X-rays show sacroiliitis with structural changes.

Non-radiographic axial spondyloarthritis

M45.A0
Use if only MRI findings are present without X-ray changes.

Documentation & Coding Risks

Avoid these common documentation and coding issues when documenting Spondyloarthritis to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code M45.A0.

Impact

Clinical: May lead to misdiagnosis or inappropriate treatment., Regulatory: Non-compliance with documentation standards., Financial: Potential for denied claims or reduced reimbursement.

Mitigation Strategy

Ensure detailed symptom documentation, Use specific diagnostic criteria

Impact

Reimbursement: May lead to lower reimbursement rates., Compliance: Non-compliance with coding guidelines., Data Quality: Decreases accuracy of clinical data.

Mitigation Strategy

Use M45.A0 if inflammatory features are present.

Impact

Risk of audits due to insufficient documentation of inflammatory features.

Mitigation Strategy

Ensure detailed documentation of symptoms and diagnostic criteria.

Documentation errors, coding pitfalls, and audit risks are interconnected aspects of medical coding and billing. Addressing all three areas helps ensure accurate coding, optimal reimbursement, and regulatory compliance.

Frequently Asked Questions

Common questions about ICD-10 coding for Spondyloarthritis, with expert answers to help guide accurate code selection and documentation.

Documentation Templates for Spondyloarthritis

Use these documentation templates to ensure complete and accurate documentation for Spondyloarthritis. These templates include all required elements for proper coding and billing.

Rheumatology Progress Note

Specialty: Rheumatology

Required Elements

  • Subjective symptoms
  • Objective findings
  • Assessment
  • Plan

Example Documentation

**Subjective:** 'Worsening nocturnal low back pain (8/10), improves with movement. Failed NSAIDs x6 weeks.' **Objective:** Tenderness: SI joints bilateral, BASMI: 4/10, Labs: CRP 12 mg/L, HLA-B27+, Imaging: MRI SIJ shows subchondral BME. **Assessment:** nr-axSpA (M45.A0). **Plan:** Initiate TNF inhibitor.

Examples: Poor vs. Good Documentation

Poor Documentation Example
Patient has back pain. Start adalimumab.
Good Documentation Example
45yo male with 2-year history of inflammatory back pain (BASDAI 6.2), HLA-B27+, MRI-confirmed sacroiliitis without X-ray changes. Diagnosed with nr-axSpA (M45.A0).
Explanation
The good example provides specific clinical details and diagnostic criteria supporting the diagnosis.

Need help with ICD-10 coding for Spondyloarthritis? Ask your questions below.

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