ICD Code M46.96

ICD code M46.96 is unspecified inflammatory spondylopathy affecting the lumbar region of the spine.

1. Presence of clinical signs and symptoms of inflammatory spondylopathy localized to the lumbar region, such as chronic lower back pain and stiffness

2. Evidence of inflammation in the lumbar spine, which may include elevated inflammatory markers (e.g., ESR, CRP)

3. Imaging findings suggestive of spondylopathy in the lumbar region, such as MRI or X-ray changes consistent with inflammation

4. Absence of a more specific diagnosis or etiology for the inflammatory spondylopathy after appropriate evaluation

5. Symptoms not attributable to infectious, neoplastic, or traumatic causes

6. Documentation of the condition as unspecified due to lack of sufficient information to classify under a more specific inflammatory spondylopathy code

Applicable CPT codes for ICD code M46.96 include:

- 99202–99215 (Evaluation and Management services)

- 20552 (Injection(s); single or multiple trigger point(s), 1 or 2 muscle(s))

- 20553 (Injection(s); single or multiple trigger point(s), 3 or more muscles)

- 20610 (Arthrocentesis, aspiration and/or injection; major joint or bursa)

- 62321 (Injection(s), of diagnostic or therapeutic substance(s) (e.g., anesthetic, antispasmodic, opioid, steroid); lumbar or sacral, single)

- 62323 (Injection(s), of diagnostic or therapeutic substance(s); lumbar or sacral, continuous infusion)

- 72148 (MRI, lumbar spine without contrast)

- 72149 (MRI, lumbar spine with contrast)

- 72158 (MRI, lumbar spine without and with contrast)

- 72080 (Radiologic examination, spine, entire thoracic and lumbar, including skull, cervical, and sacral spine if performed, minimum of 2 views)

- 97110 (Therapeutic exercises)

- 97112 (Neuromuscular reeducation)

- 97140 (Manual therapy techniques)

- 99217–99239 (Hospital observation and inpatient care services, if applicable)

CPT code selection should be based on the specific services rendered and clinical documentation.

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