ICD Code M48.48XA

ICD code M4848XA is used to classify a fatigue fracture of the vertebra located in the sacral and sacrococcygeal region, specifically during the initial encounter for the fracture. This code is part of the International Classification of Diseases (ICD) system, which is used by healthcare providers to document and categorize diagnoses and medical conditions. The "M48" series pertains to disorders of the spine, while the "48XA" specifies the nature and location of the fracture, indicating that it is a stress-related fracture in the lower spine area, and the "A" denotes that this is the patient's first visit for this particular fracture. This code is crucial for accurate medical record-keeping, billing, and ensuring appropriate treatment and follow-up care.

When to use the ICD code M4848XA, consider the following diagnostic criteria and symptoms:

1. Presence of Fatigue Fracture: Confirm that the patient has a diagnosed fatigue fracture in the vertebra, specifically in the sacral and sacrococcygeal region.

2. Initial Encounter: Ensure that this is the first encounter for the fracture, indicating that the patient is seeking treatment for the injury for the first time.

3. Clinical Symptoms:

- Localized Pain: The patient may report localized pain in the lower back or sacral area.

- Increased Pain with Activity: Pain may worsen with physical activity or weight-bearing activities.

- Reduced Mobility: The patient may exhibit limited range of motion or difficulty in movement due to pain.

- Tenderness on Examination: Physical examination may reveal tenderness over the affected area.

- Radiological Evidence: Imaging studies (e.g., X-rays, MRI) should confirm the presence of a fatigue fracture in the specified region.

4. Exclusion of Other Conditions: Rule out other potential causes of back pain or fractures, ensuring that the diagnosis specifically aligns with a fatigue fracture.

5. Patient History: Consider the patient's history of conditions that may predispose them to fatigue fractures, such as osteoporosis or previous trauma.

6. Duration of Symptoms: Symptoms should be recent and correlate with the onset of the fracture, typically following a period of increased physical stress or activity.

By adhering to these criteria, healthcare providers can accurately determine the appropriate use of the ICD code M4848XA in their documentation and billing processes.

For the ICD code M48.48XA, which pertains to a fatigue fracture of the vertebra in the sacral and sacrococcygeal region during the initial encounter for fracture, the relevant CPT codes that may be applicable include:

1. 22325 - Open treatment of vertebral fracture(s), sacral; with or without internal fixation.

2. 22326 - Percutaneous vertebroplasty (bone cement injection) for vertebral fracture(s), sacral.

3. 22327 - Percutaneous vertebral augmentation, including cavity creation (fracture reduction and bone biopsy included when performed) using mechanical device (e.g., kyphoplasty), sacral.

4. 27216 - Closed treatment of sacral fracture; without manipulation.

5. 27217 - Closed treatment of sacral fracture; with manipulation, with or without traction.

6. 27218 - Open treatment of sacral fracture, includes internal fixation, when performed.

These CPT codes are examples of procedures that might be considered for treating a fatigue fracture in the sacral and sacrococcygeal region, depending on the specific clinical scenario and treatment plan determined by the healthcare provider. Always consult the latest CPT code manual and payer policies for the most accurate and applicable coding.

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