ICD-10 Coding for Spondylosis Without Myelopathy(M47.816, M47.812)
Complete ICD-10-CM coding and documentation guide for Spondylosis Without Myelopathy. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Spondylosis Without Myelopathy
M47.81xPrimary Range
Spondylosis without myelopathy or radiculopathy
This range includes codes for spondylosis affecting different regions of the spine without myelopathy or radiculopathy.
Code Comparison: When to Use Each Code
Compare key differences between these codes to ensure accurate selection
| Code | Description | When to Use | Key Documentation |
|---|---|---|---|
| M47.816 | Lumbar spondylosis without myelopathy or radiculopathy | Use when lumbar spondylosis is present without symptoms of myelopathy or radiculopathy. |
|
| M47.812 | Cervical spondylosis without myelopathy | Use when cervical spondylosis is present without symptoms of myelopathy. |
|
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 lumbar spondylosis without myelopathy
Essential facts and insights about Spondylosis Without Myelopathy
Primary ICD-10-CM Codes for spondylosis without myelopathy
Decision Criteria
clinical Criteria
- Imaging shows degenerative changes without nerve compression.
documentation Criteria
- Detailed imaging findings and absence of myelopathy symptoms.
Applicable To
- Degenerative changes in lumbar spine without nerve involvement
Excludes
- Lumbar spondylosis with myelopathy
- Lumbar spondylosis with radiculopathy
Clinical Validation Requirements
- Imaging showing degenerative changes without nerve compression
- Physical exam ruling out neurological deficits
Code-Specific Risks
- Confusion with M54.5 for non-specific back pain
Coding Notes
- Ensure documentation specifies absence of myelopathy and radiculopathy.
M47.812 - Cervical spondylosis without myelopathy
Use when cervical spondylosis is present without symptoms of myelopathy.
Applicable To
- Degenerative changes in cervical spine without nerve involvement
Excludes
- Cervical spondylosis with myelopathy
- Cervical spondylosis with radiculopathy
Clinical Validation Requirements
- Imaging showing osteophyte formation with preserved spinal canal diameter
Coding Notes
Document absence of neurological deficits.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Low back pain
M54.5Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting Spondylosis Without Myelopathy to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code M47.816.
Impact
Clinical: May lead to misdiagnosis, Regulatory: Triggers coding queries, Financial: Potential reimbursement denial
Mitigation Strategy
Specify 'spondylosis without myelopathy', Include detailed imaging findings
Impact
Reimbursement: Avoids DRG 551→552 shift (+$3,200 reimbursement), Compliance: Ensures accurate coding for audit purposes, Data Quality: Improves data accuracy for clinical research
Mitigation Strategy
Code M47.816 first, M54.5 as secondary.
Impact
Using M54.5 instead of M47.816 for spondylosis-related pain.
Mitigation Strategy
Educate staff on correct code selection and documentation requirements.
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 Spondylosis Without Myelopathy, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Spondylosis Without Myelopathy
Use these documentation templates to ensure complete and accurate documentation for Spondylosis Without Myelopathy. These templates include all required elements for proper coding and billing.
Neurosurgery H&P
Specialty: NeurosurgeryRequired Elements
- History of Present Illness
- Physical Examination
- Imaging Results
- Assessment and Plan
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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