ICD Code M48.46XG

ICD code M4846XG is used to classify a specific medical condition related to the spine. This code indicates a fatigue fracture of a vertebra located in the lumbar region, which is the lower part of the spine. The fracture is a result of stress or overuse, rather than a sudden injury. The "subsequent encounter" part of the code signifies that the patient is receiving follow-up care for this condition. The mention of "delayed healing" indicates that the fracture is not healing as expected, requiring additional medical attention to address the prolonged recovery process. This code is crucial for healthcare providers to accurately document the patient's condition and ensure appropriate treatment and billing.

When to use the ICD code for a fatigue fracture of the vertebra in the lumbar region, subsequent encounter for fracture with delayed healing:

1. Diagnosis Confirmation
- A confirmed diagnosis of a fatigue fracture in the lumbar vertebrae.

2. Subsequent Encounter
- The patient is returning for follow-up care after the initial treatment of the fracture.

3. Delayed Healing
- Evidence of delayed healing as indicated by imaging studies (e.g., X-rays, MRIs) showing no significant improvement in the fracture site.

4. Symptoms Present
- Persistent or worsening pain in the lumbar region despite treatment.
- Limited mobility or difficulty in performing daily activities due to pain or instability.
- Neurological symptoms such as numbness or weakness in the lower extremities, if applicable.

5. Treatment History
- Previous interventions have been attempted, such as physical therapy, pain management, or surgical options, without successful healing.

6. Patient History
- Relevant medical history that may contribute to delayed healing, such as osteoporosis, diabetes, or other comorbidities.

7. Documentation
- Comprehensive documentation in the medical record detailing the diagnosis, treatment history, and current symptoms to support the use of the specific ICD code.

For the ICD code M48.46XG, which pertains to a fatigue fracture of the vertebra in the lumbar region with delayed healing, the relevant CPT codes that may be applicable for treatment include:

1. 22325 - Open treatment of vertebral fracture(s), lumbar, using internal fixation.

2. 22326 - Percutaneous vertebroplasty, lumbar, including bone biopsy, when performed.

3. 22327 - Percutaneous vertebral augmentation, including cavity creation (fracture reduction and/or bone biopsy included when performed) using mechanical device (e.g., kyphoplasty), one vertebral body, unilateral or bilateral cannulation (e.g., kyphoplasty), lumbar.

4. 22533 - Arthrodesis, anterior interbody technique, including minimal diskectomy to prepare interspace (other than for decompression); lumbar.

5. 22840 - Posterior non-segmental instrumentation (e.g., Harrington rod technique, pedicle fixation across one interspace, atlantoaxial transarticular screw fixation, sublaminar wiring at C1, facet screw fixation).

6. 99213 - Established patient office or other outpatient visit, typically 15 minutes.

These CPT codes are examples of procedures that might be considered in the management of a lumbar vertebral fracture with delayed healing. The selection of specific CPT codes would depend on the individual patient's treatment plan and the healthcare provider's clinical judgment. Always consult the latest CPT code manual or a coding specialist for the most accurate and applicable codes.

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