2025 ICD-10-CM code M46.4
(Active) Effective Date: N/A Dorsopathies - Spondylopathies (M45-M49) Diseases of the musculoskeletal system and connective tissue (M00-M99) Feed
Inflammation of an intervertebral disc without specification of the cause.
Medical necessity for imaging and other diagnostic tests is based on clinical suspicion of discitis based on patient presentation and risk factors. Medical necessity for treatment (antibiotics, pain management, bracing) is established by the diagnosis of discitis.The type and duration of treatment depend on the cause, severity, and patient's response.
Diagnosis involves physical exam, imaging (MRI, bone scan), blood tests (CBC, ESR, CRP) and possibly cultures to identify the infectious agent. Treatment typically includes antibiotics, pain management, bracing, and activity modification. Severe cases may require surgery.
In simple words: Discitis is when the cushion between the bones in your spine gets inflamed, causing back pain and stiffness. This code is used when the doctor doesn't specify what caused the inflammation.
Discitis, unspecified, indicates inflammation of the intervertebral disc space due to infection (bacterial, viral, or fungal) or autoimmune disorders, but the specific location and cause are not documented.It can cause severe back pain, stiffness, and difficulty moving. If left untreated, it can lead to complications such as disc damage, spinal deformity, and nerve compression.
Example 1: A 6-year-old child presents with severe back pain, fever, and difficulty walking.An MRI reveals inflammation of the intervertebral disc space, consistent with discitis.The cause is not specified., A patient with a history of intravenous drug use develops back pain and stiffness.Imaging studies confirm discitis, but no specific cause is identified., A patient post lumbar surgery develops severe back pain, tenderness, and limited mobility. Imaging shows discitis, but the causative agent is not identified.
Documentation should include signs and symptoms (back pain, stiffness, fever), physical exam findings (tenderness, limited range of motion), imaging results (MRI findings), laboratory results (if applicable), and clinical impression of discitis. If the cause is known, it should be documented.If discitis is suspected, the provider should order additional testing to determine the cause.
** For accurate coding, it's essential to distinguish discitis from other spinal conditions.If the type of discitis is unspecified, M46.4 is used.This code is not to be used for post-operative discitis, for which specific codes exist.
- Payment Status: Active
- Specialties:Infectious Disease, Orthopedics, Rheumatology, Neurosurgery, Pain Management
- Place of Service:Inpatient Hospital, On Campus-Outpatient Hospital, Off Campus-Outpatient Hospital, Independent Clinic, Physician's Office